Oh My God I Got It!

[Jason Silvernail]

Well, I finally got it.

I met Barrett at the APTA conference last week, and he was nice enough to not only buy my wife and I breakfast, but also demonstrate handling and correction on both of us. Now I see why his workshop is not so popular. He must be a jerk. :)
I really couldn't help but start to laugh when my ideomotor motion started, and was amazed that it truly was as he said it was. Not that I doubted, but I did have trouble getting it to work.

Well, today, it worked on two patients of mine, with disparate areas of pain, who improved immediately in their autonomic state, pain complaints, and even findings on neurodynamic exam!
In the interest of full disclosure, I did have two patients that sort of stood/sat there, clearling stopping their isometric activity and holding themselves in a certain posture, preventing correction. So not exactly 100%, buy surely better than I was doing before.

I mention all this not to brag or take up forum space, but just to help make clear what I was NOT doing earlier, in the hopes I could help others.
1. I was pushing too hard earlier. I was very surprised how light of a contact required, and clearly was resting too heavily on patients before, which might have inhibited their movement.
2. I was doing a lot of explanation and "scene-setting" when I probably should just jump into it. I know Barrett doesn't like to tell us what to say or do exactly, but it helps to get me started sometimes, and after that my therapeutic metaphors develop. So my "lead-in" was quite short today.

In one case, my patient had had a R shoulder Rotator Cuff repair in FEB06, and was now recently having more and more pain in the shoulder, which she couldn't understand. The shoulder mobilization and RC and periscapular strengthening I was doing wasn't working to make it better. A shocker, I know. Anyway, she had also had a carpal tunnel release on the same side, and complained of "trigger points" in her neck on that R side. Her ULNT median was short and painful. After about 10 minutes of correction, her ULNT was normalized and her shoulder ROM was immediately significantly improved.

The other patient I had for first visit, and she had chronic buttock and leg pain. She had had multiple epidural steroid injections and an SIJ injection, which had helped and she said had "diagnosed" her problem as an SIJ problem. She had reported temporary relief with manipulation and massage before. There were 2/5 manipulation criteria (not a good candidate), no centralization with repeated motion, weakness of hip muscles in single leg stance, and TTP at her L SIJ area, and 3/6 SIJ provocative testing. Previously, I would call her a good candidate for lumbar stabilization exercise, and preliminary CPR for success with this made her a good candidate. But, I was fresh off my success with my patient with shoulder pain, so I tried SC first.
This patient actually leaned forward and walked her hands out in front on all fours with knees bent before saying "ahh...that's the spot." She felt warmer immediately, had no pain with lumbar extension where previously there was some, and a negative slump test where previously she had about jumped off the table.

I could get used to this...

J

[Diane]

Jason, consider yourself ruined for good! :teeth: :thumbs_up

[nari]

Jason,

Did you feel as though all the complex things we do, ie : stretching/mobing/contracting/relaxing/analysing/evaluation was all rather unnecessary and vaguely nociceptive??

I did.

Nari

[Jon Newman]

Nice to hear Jason and I appreciate hearing what you felt was going wrong before. In other words I didn't mistake your contribution for bragging.

Were the patients able to continue on their own?

[Barrett Dorko]

Jason,

I'm not surprised. It should be noted however that buying breakfast for a couple of vegans isn't like buying for a steak and eggs guy like me. You're a cheap date. Please don't tell your wife I said that.

I'm guessing that you gave the two patients who didn't move something to resist. Here's my advice for next time:

Don't do that.

[Jason Silvernail]

Jon-
I beleive they were, but to be honest, I didn't remove my hands while they were correcting, so I guess it's hard to say.

I talked about autonomic balance and practicing, and said if they couldn't do as well without me in a week, they should call and I'll bring them back in. This sort of followup is common for my manual therapy patients.

I guess we'll see...

J

[Baecker]

hi jason,

thanks for sharing sounds interesting.

i would like to know about the 2 patients you applied sc on. what was their initial starting position and where did you place the hands on? did they lay on their backs or standing or what?
what did you tell your patients before?
i must say i seem to have patients which don't start to move. sometimes they move if i let them lay down and hold their head, then some move but only the neck noting else.
any tips? from what i understand sc is that the touch is light and no coercion is being done. i sometimes though exaggerate a position they are already in if they don't start to move.

[Luke Rickards]

That's great to hear Jason. It sets your mind whizzing when you realise how easy it is, doesn't it?

I also found very early on that a lot of explanation is not necessary to illicit the movement, although it may be useful later on.

Luke

[Barrett Dorko]

I agree with Luke that explanations later in the course of care are more useful than those given sooner. In fact, initially the patient might find them quite distracting. In my culture I think it's fair to say that pretty much everyone is touch-starved and thus will not need any special preparation for it. I'm pretty sure they aren't starved for coercive touch though.

I hope Baecker that you will one day understand that it isn't the starting position that's important. Every position has its advantages and disadvantages and I swear I don't work with my patients in any sort of sequence. It's also important to remember that the characteristics of correction take presedence over the movement you can easily see.

Baecker, I appreciate your curiosity but you're asking the wrong questions. I say that because the answers aren't going to help you understand this method. Having taught it for a couple of decades I feel I can say that with some confidence.

[Mike Terrell]

Jason,

What kind of explanation did you use? I have had the same problem talking too much and not just getting started. Each time I have tried to explain SC to a pt. I think of one of the quotes at the bottom of Diane's post about not understanding something until you can explain it to your Grandma.

I realize Baecker already asked about this, but I would like to hear how you approached the pt. (not physically approached, but verbally).

mike t

[nari]

Jason

It helps to think that there should be some air between your touch and the patient's body surface. That keeps it light and in no way coercive.

I agree that explanations prior to actual SC should be minimal; too much information will rattle up anticipation and other cognitive processes. I would think about 1 minute or so, to begin with.

Nari

[Diane]

Jason, now that you've "got it" I expect you could become quite a maven or connector or whatever it is that is necessary to get to that tipping point some day. :) Meanwhile, I think we all need to lift our share of the canoe of abductive thinking during the long portage upstream along Mesoderm river to Ectoderm lake around the Grand Rapids of cultural indifference.

[Synergy]

Jason,

Thanks for sharing your insight! Maybe I'm pressing a bit too hard on my patients as well, inhibiting their 'corrective' movement. From what Nari said regarding time spent discussing/informing the patient taking ~ 1 minute, I better change that as well. I have always over-explained things...brevity is something I need to learn I suppose.

Barrett,

Feel free to come down to Forney, TX (20-30 miles East of Dallas) and buy my wife and I breakfast. She's pregnant and I'm a steak and eggs guy myself. I promise you a more expensive ticket than the Veganator. :)

[nari]

Chris,

I'm developing a basic 1 page document talking about the nonconscious vs the conscious mind; I found some years ago a "sheet for patients" helped me with the subtlety of clinical neurodynamics, during a period when many PTs abandoned neurodynamics because it "didn't work" or "caused too much pain", I decided that the CNS needs very little done to it, but it must be of the right nature and sequence.

Perhaps, typing out an explanation of ideomotion and SC in 1 page only, will help to make thinking effectively succinct. Then give it to a 12 year old to read - someone with no understanding of neuroscience - and see if it 'gels' with him/her. If it doesn't...you can blame the kid (or the information). ;)
Then, take some crucial sentences from the text and this can be a starting point for the intro for a clinical session.

Just a suggestion.

Nari

[Baecker]

hi,

even though I might ask the wrong questions but I still would like that Jason could answer if he has the time.
Reason that I am asking is because that I am experementing with SC and if a patient lays prone on the table and I am having my hands on their heads I never had one yet to get up on its four or turn around or whatever, all what I experienced so far it that they move their heads/necks in odd ways. Often they also fall asleep.
Since traveling to the US and taking a course will be a bit far for me as well expensive so I try to figure out as much I can here. I apologize for the wrong questions but they are important for me at this time.

[Synergy]

Nari,

Good idea! I have printed out several of Barrett's essays since I first saw his website and have read them each a few times in hopes of 'getting it'. Needless to say, I have yet to reach that point. However, your idea may at least assist my presentation to my patients and I'm sure I'll learn more in the process. Thank you! ;)

Mike,

I'm not sure if the following will be of any help to you, but I've approached my patients with the scenario mentioned in Barrett's essays regarding a child sitting in a classroom...wanting to move and stir about but is not allowed because he/she may get in trouble, i.e. creating a suppression of movement. I've tried to portray examples for my patients like the above as well as adding in some 'simple' and easy to understand physiology.

Baecker,

I'm not sure it matters if your patient, who is lying prone, suddenly assumes a quadruped position. I wouldn't consider this a failure, but rather your attempt at trying to predict their movement which may lead to a predetermined effect of your treatment [read: coercion].

[nari]

Baeker,

Why prone? Was it your choice or the patient's?

The position doesn't matter; what counts more, by my reckoning, is that the patient is free to move. Perhaps sitting or standing, but ask them what they would prefer; after all, we do an awful lot of ordering patients around into positions - it makes a pleasant change that they can choose for themselves.

Nari

[Jason Silvernail]

Well, even though Baecker's questions were my own at one time, I feel I shouldn't go into too much detail. I'm afraid that if I say doing X worked for me, then some will try only X and it may not work for them.

But, here's a try: I explain to them that the body does three things in response to pain (withdrawal, protection, resolution- from Patrick Wall). I give them examples of stubbing their toe or me twisting their finger. Then I tell them that they are stuck in the "protection" phase, and I adopt a protected posture to emphasize - face grimacing, shoulders raised, hands in fists, etc. Then I tell them that their body needs to move to resolve the problem and I can help them with that. I have had best luck in standing, and just touch LIGHTLY at lateral shoulders, and they start to move in less than 3 seconds. After about 10 seconds, I ask about correction characteristics, and in every case they've said their involved part or another painful part has felt hot like blood rushing to it. Then I retest their neurodynamic exam and it is almost completely symmetric, and one patient was completely asymptomatic. They turn and usually give me this "How'd you do that?" look, and I explain that the motion is in their body, they need to trust it and practice several times a day. I talk a bit about abdominal breathing and hip abduction, and we're done.
So this is really not much as far as setup goes. I may be doing/saying too much as it is.

Barrett is right about not really needing to be taught any specific technique, but somehow it really helped to have him show me in person, not sure why. I'm sure all sorts of other positions and setups could work equally well, but I haven't tried that as yet.

Not sure if that helps, but there it is...
J

[Jon Newman]

but somehow it really helped to have him show me in person, not sure why

Two words: Mirror neurons.

It's the same reason the patient will benefit more from seeing and talking to you. It is simply how we're wired and I think touch tends to drive it home even more efficiently than say a "video presentation" or something similar. Think about when your friend has something cool and you say "Let me see that" and reach out with your hands. Your friends holds it up and away from you and slyly says "See". You end up disappointed and not just at your belligerent friend.

[Mike Terrell]

Jason,

Yeah, that helped. How you approached the explanation of SC to the pt. was my main interest. I'm certain I have talked SC to death with pts. before I even touched them.

Nari,

I like your idea as well. Having something ready before hand would help me organize my thoughts and keep the discussion to what is important.

By the way, I will be moving to a new clinic in the near future where I will be the lone PT. Should be quieter, calmer and a better enviornment to talk with and educate pts.

mike t

[Diane]

Baeker, your post reminded me of something, when you said your patients were prone; that's how infants develop their spinal movement against gravity. If supine they learn to roll their head from side to side, but if they are prone they learn to lift them up and move them around. There's something interesting about that here, on this Jason/SC thread, but I'm not sure what. Any clues Barrett?

My little postulate, for now, is that maybe patients are flushing out the pipes of their motor programs from the very oldest layer forward.

[Jason Silvernail]

Well, I've had two more successes, one yesterday and a big success again today, and I am slowly reducing the amount of "scene-setting" I'm doing.
It continues to be in standing, and the results continue to be impressive, more so for the patient than me.
It was all I could do to keep from laughing out loud when I saw an upper limb neurodynamic test change 180 degrees in 5 minutes of corrective movement.

I see why Barrett is so guarded about speaking of clinical outcomes - while they are often impressive, the "testimonial" nature of them is problematic.

J

[Baecker]

hi,

ooops i messed up prone and supine :(

i ment supine. but yes this helped me a great deal more than you can imagine. i will try this definetly out and yes i understood that the position is not important. still i guess for someone with low back pain it seems to be more logical to start standing or sitting or on all four? or is that incorrect?
what about patients falling asleep?

[Barrett Dorko]

Baecker,

I suspected you meant supine. Please, I only speak English, and when others contribute here in something other than their native tongue I certainly admire the courage that takes.

In any case, I work with people while they are supine a great deal. It's a good idea for a number of reasons, and there are other good reasons for working in standing or sitting. Let the patient lead you from one to the next.

Diane,

I've heard many people comment about how the developmental sequence of posturing might be related to ideomotion but I've never, never seen the idea go anywhere. It seems to be a non-starter.

[Jason Silvernail]

I Worked with a patient with complaint of "costochondritis" today.
Previously, he did not tolerate attempts at manipulation/mobilization.

After a few minutes of ideomotor movement in standing and then supine, he felt a strong warmth in his chest area, and his complaints improved.

I'm not sure how he'll do in the end, but it was my first experience with this in supine. I was holding his head off the surface and trying to allow movement as much as possible. I wonder if by holding up his head I was helping him or coercing him. Thoughts?

Anyway, it sure beats the supine sternocostal manipulation. Boy, that one is hard on both patient and therapist. I have a video of it from one of Flynn's manual therapy CDs, but can't post an mpeg here. Suffice to say the setup is difficult and predicting whether it will help is even more difficult...

J

[bernard]

Jason,

I added the mpeg type to the board.
You may normally be able to make an attachment.

[Randy Dixon]

I don't know about anyone else but I'm really tempted to go get some of Jason's first posts to Barrett on RE. He's almost gone full circle.

Well, I'd like to tease him about it but his ability to keep an open mind without abandoning skepticism is something I find admirable.

[nari]

Jason,

I know exactly what you are experiencing - although I am not practising SC yet, I have achieved similar results with 2-3 minutes of neurodynamics on some four month old "frozen shoulders".

It makes one really understand and appreciate what pain is really all about.....and it's not to be found in the 'bibles' of PT practice. Sad.

Nari

[Diane]

What would "full circle" be in the reasoning lexicon? We have deductive, inductive, abductive.. maybe this would be "circumductive": Able to reason all the way around the equator of a problem.

This is my favorite (a kind I made up) "sphere-o-ductive": Inward or outward reasoning along any (of an infinite number of) vectors perpendicular to a problem.

[Jason Silvernail]

Yeah, Randy, I do recall that Barrett and I didn't exactly hit it off right away.
Funny, when we met at APTA, I could have sworn we'd known each other for years.

Thanks for the compliment about the open mind. I think any EBP-minded therapist would approach SC the way I have, if they only take the time to REALLY investigate the approach. But that's the thing. You've really got to take the time and effort to examine what Barrett proposes in order to understand it, and make an argument. I suspect that that's what the problem is.

But it's really kind of impressive what the patients are reporting. I had a patient today with chronic neck and back pain, who was not improving on the previous treatment of occasional manipulation (gave temp relief only) and lumbar stabilization/motor control exercises. We did a little SC today, and she went from 5/10 pain to 0/10, with improved spinal ROM. It was impressive to see the parasympathetic shift, she said she felt warm and tired afterward.
It really makes a lot of what I was previously doing seem unnecessary.
I've definitely got the cautious optimism going so far...

J

[Barrett Dorko]

I agree, we found a way of communicating that would have fooled anybody else into thinking we'd done it all before. This is especially rare for me.

Rapid and dramatic change as you describe is common. Today in Sioux Falls a woman changed similarly while I handled her and lectured simultaneously. She stated that her painless range improved to places she "hadn't been for years," and I could see no reason not to believe her.

What's of greatest interest to me is the reaction of the therapists witnessing this. They seemed not especially impressed. If they were, their thoughts will turn elsewhere very soon and most work with others that not only won't believe them, they'll discourage their pursuing the method or thinking further. This will be done non-verbally for the most part. That makes it more effective.

You may be the first actual "in-charge" therapist I've had understand things as you do. Perhaps that's what makes your experience so different than others.

By the way, I never take the head off the end of the table in supine. If the patient unconsciously desires cervical extension I'll just let that happen in any one of a number of alternate positions.

[Luke Rickards]

Jason,

I'm interested in how you go with the costochondritis patient, since this condition is primarily inflammatory in nature (if the diagnosis is correct).

If never heard of a sternal manip before, and I'm no stranger to HVLA. I image it to be quite harrowing. What does it attempt to cavitate?

Luke

[Diane]

If never heard of a sternal manip before, and I'm no stranger to HVLA. Is it called the 'manubrial whip'? (:rolleyes: )

[Jason Silvernail]

Luke-
I look at costochondritis the same way Barrett says he looks at "adhesive capsulitis" - with suspicion. I think that "diagnosis" was the physicians way of saying "musculoskeletal chest wall pain at the sternocostal area".
It does not have the hallmarks of chemical pain by history, and the anti-inflammatory drugs he's been prescribed don't work. So that throws the diagnosis into a bit of a question. :)
I'll let you know when he comes in again and what i'll do to treat him, and how he's doing.

Barrett-
Perhaps you're right, my relative position of authority makes it easier for me to treat as I see fit without worrying about pressure from others. If that's the case, then so much the better.

Bernard should be posting the short video clip of the 2nd rib manipulation I'm speaking of, as I couldn't get it to load. It's from a manual therapy CD by Flynn/Whitman/Magel, and is excellent for learning/reinforcing manipulation. So that's nice. :)

J

[bernard]

Well, I added the movie but it doesn't work.
I must change some settings on the board.

You must save the file before read it. Just right click on the link and choose the right option.

The server doesn't allow direct streaming.

[EricM]

Bernard, it played just fine for me. You've gotta love the delayed sound effects!

eric

[bernard]

Eric,

I got it! (those damned cache files!:D)

[Jason Silvernail]

Well, in my outpatient Ortho/sports world, I am noticing a group of people who consistently do very well with SC....patients who are postop from shoulder surgeries. Sometimes their progress slows/stops, pain increases, and N&T complaints to hand.
Every patient like this i've tried it on ( 5 so far) has done wonderfully, with signficant improvements in their pain and neurodynamic exams.

I now don't say anything much before starting, just something like, let's see if I can help you find your way out of this pain you're in....and then I verbally encourage the ideomotion when it happens. I am now saving the explanation for, as Luke and Barrett suggest, after the treatment.
Hope that's helpful for those just starting to try this out...

J

[Barrett Dorko]

Jason,

Great to hear. Have you seen any correlation with the ipsolateral hip resting posture? I'd predict it's there 80% of the time.

As you've discovered, these patients represent "an orthopedic problem gone bad" or, to put it more accurately, "an othopedic problem with a neurologic component/solution."

I'll be in Virginia in September. Sorry you'll be in Heidelberg. Send some staff instead.

[Diane]

As you've discovered, these patients represent "an orthopedic problem gone bad" or, to put it more accurately, "an othopedic problem with a neurologic component/solution." Or, a neurologic problem that got culturally stuffed into an orthopaedic category by fluke or by design.

[Barrett Dorko]

Jason,

One more thing. It sounds like you've discovered how to "do nothing" and "understand enough." This is remarkably powerful in the right context.

This "doing nothing" is especially well-suited to the Army, of course (ha,ha). I've heard rumors.

Diane,

I've had to come up with my own definition of "orthopedic problem." It includes mesodermal structures that require healing or repair or strengthening for full recovery. All of this might happen of its own accord without therapeutic instruction or surgery but they, at times, are certainly necessary.

For some of these, an intricate and significant alteration in the neurology must take place as well, perhaps almost entirely. I think this "balance" may shift in either direction and would have difficulty saying where or when the tipping point from one to the next might occur. It's likely that the patient will indicate this in some way, probably through the expression of their autonomic state. We know that this can be difficult to measure and interpret.

No doubt cultural attitudes as expressed by the therapist play a role as well, both consciously and unconsciously.

Sarah Vowell's description of the Canadian Mountie as opposed to the American Cowboy fits perfectly here: "Canada got Mounties - Dudley Do-Right, not John Wayne. It's a mind-set of "Here I come to save the day" versus "Yipee-ki-yay, (insert powerful expletive here)."

I had a feeling you might like that.

[Jason Silvernail]

I actually have noticed the hip thing - though right now I am having better luck in standing and sitting than supine so I don't have an opportunity to see everyone in that position.

But I have to agree with the orthopedic/neurologic difference you mentioned, I think that's exactly right.

I had a guy just the last few minutes who improved his Cx rotation from 10 degrees to nearly full in just a few minutes.

I now know I'm going to do my case study/review article for my DPT program on simple contact, I just need to find an appropriate patient to do a review of. Will keep everyone posted.

J

[Diane]

Wow Jason, that could turn you into not just Barrett's new best friend but you could help the whole profession redesign itself. OK.. Back up Diane. I'm being too ambitious for you.

[nari]

Jason,

Sounds like good stuff. I know I am diving in at the deep end starting with very complex patients, but that is how I chose it. Call me a geek for uncertainty.

I think supine is the most challenging position for SC and have not gone there yet.

Do you use SC on yourself with success?

Good luck with the study.

Nari

[Luke Rickards]

Jason,

Think about doing an SSRD for your review instead of a case study. They are quite similar but an SSRD offers stronger evidence, and SC could do with more of this. I can send you some info on SSRDs if you like.

Luke

[Barrett Dorko]

Over the years I've found that for some reason people will choose a "favorite" position to allow their patients to get into before they employ Simple Contact.

Personally, I don't have one, though I often find myself sitting quietly at the patient's head while they're supine, the characteristics of correction popping up all over the place but relatively little motion to see.

[Luke Rickards]

I have not yet developed a favourite position either, and will often use 3-4 in one session in no pre-chosen order.

In the beginning I felt more comfortable in the standing and sitting postions, only because the movement was more dramatic and thus appeared more impressive and effective. Now I work in supine more often. I am finding that the finger tips of one hand on the lumbar SPs or PSIS and the other at the medial malleolus and/or 1st MTP is an extremely effective contact for encourgaing external rotation at the hip.

Luke

[Bas]

I love sitting and feeling my head go all over "heaven's" half acre. More successful on myself at the moment - am not always quiet enough inside for my patients yet. getting better. I love the pauses in my head/neck's motion, as if the system says: "Wait here for a bit, this needs to soften for a moment"....Funny, the mention of "orthopaedic/neuro": I also noticed when I let my own head/neck gently correct, I get some very smooth, but noticable joint "pops" on occasion. It is of course, a gentle action, moving into a soft but audible pop and followed by warmth. No HVLA needed ....

[Jason Silvernail]

Luke - I'll PM you about details. Thanks.

Bas -
It's so funny you posted that. I spent yesterday in the afternoon trying to correct my chronic but now subacute and painful Lx radiculopathy in my R leg. I just now finished setting up my workstation so I can stand all day now.
I figured out last night that it was chemical pain, and felt better after a blast of NSAIDs.
Much better today, but most frustrating for me is that now that I can elicit this motion in my patients, I'm having the most difficulty with it myself. Ironic, huh?

I'm hoping to have a few attempts at it tonight, since it seems more mechanical today, with my wife to help, since I can't seem to get it going without touch to set it off. While certainly annoying, it sure does make everything in the "Touch and Sensation" essay make personal sense.

J

[OaksPT]

Jason,
I know exactly what you mean, it seems much harder for me to treat myself, when I have the rare flare-up of scapular pain from too much computer time.
As Barrett mentioned, I have a favorite position for my patients(standing), as the results seem more dramatic, but I am slowly gaining confidence and trying the patients in different positions.
Scott

[christophb]

Jason, I’ve found the very same to be true, easier to elicit in patients, much more challenging in myself. It does get better with practice, but my learning curve has been long.

I had an interesting revelation with a "RTC tendonitis" patient the other day. I usually explain too much right away, and I noticed I have a tendency to judge whether people will "get SC" or not and introduce it accordingly. The gentleman from yesterday did not fit my "looks like he'll enjoy SC category" but I went ahead with it anyway, no explanation given. As I expected, there was not much movement going on and I was disappointed and a little worried he would think I was weird. It was then I realized I was weird, but also that I was giving most of the resistance to movement. When I gave him nothing to resist, the characteristics emerged and movement followed. It was such a subtle shift though that it surprised me. He walked out surprised and pain free as well.

I have printed up a characteristics of correction sheet that I give people, and I am thinking of posting it for deconstruction/ideas (my one act of bravery for the day). It seems to be working as I have had more patients with "ah ha" moments while doing self-ideomotion. Plus I personally don't like to talk about it while doing SC, I haven't learned to multitask that yet.

Chris

[EricM]

Those are some excellent descriptions Chris, not weird at all. Brief and to the point, which will be easy for patients to take in. I on the other hand wanted to read more, hope you keep writing these!

eric

[nari]

These are good ideas, Chris. Keep 'em rolling.

I might suggest that a therapist doesn't say a word at all during SC - nothing, until the movement ceases. Do we really want to 'interfere' with what awareness the patient is about to, or is experiencing, or has just experienced?
I would have 'instinctively' thought we shut up until resolution has finished.

Just an idea...

Nari

[Barrett Dorko]

On the other hand, I often talk a great deal while people move. The subject matter is eclectic as well.

It's also common for me to be perfectly quiet. I have no idea what triggers what. I will often interrupt myself to say something about what I'm sensing or to ask what people are feeling. I find myself repeating the theory behind the work with a new analogy. To me, it often becomes something like the writing I do each morning. I don't know what's going to show up next.

I will admit that I've been known to say exactly the wrong thing at the worst possible moment. I try to avoid that, but, well, such a thing will never disappear entirely. Not until I'm no longer able to talk at all.

That should do it.

[Rolf-Inge]

Hi!
Ihave to saythat iam quite impressed with your results using SC,but for how long does your pos results last?
Do your patients learn SCon them self to be able to take controll of their own problems.?
Do you consider Sc as an active or passive approach?

RIN(Still in doubt!)

[nari]

RIN,

The follow-up of patients after discharge from physiotherapy is always interesting; particularly those who have only experienced SC. I'd like to know that, too.

Ideally patients learn to become aware of instinctive corrective movements themselves, and physios will become redundant. ;) But that is not a welcome thought for the muscle/joint aficionados...

There is nothing passive about SC - the therapist does nothing. Therefore it is 100% active.

Nari

[Jon Newman]

Hi RIN,

I consider Simple Contact to be as active of a therapy as you can get and still be providing manual therapy. Of course their movement (palpable or visible) and our understanding of the mesoderm, ectoderm and recognition of aberrant presentations is the crux of the therapeutic interaction and that, in my opinion, makes us the professionals we are.

[nari]

...and given my reductionist philosophy, the knowledge we have in varying depths is that important aspect of patient/therapist interaction, be it tactile or verbal or both, that many others fail to realise, including our peers and superiors, still clinging to the meme that we treat only mesoderm in a physical sense.

When can we become Pain Pathologists??

Nari

[Bas]

Jason, Scott: maybe I'm just so much more self-centered than you two....
Mind you, I have done trancendental meditation in the 70's before I became a physio and I think that may have an effect on getting myself quiet inside for me. I haven't always been able to bring that "older" skill to override my more recent well-established and trained professional mind-set of "I gotta think this out- deduce, investigate, find the problem" - this mind set is a big and noisy fortress to level. Gotta find that secret tunnel...

[Bas]

RIN, your question needs a bit of clarification. What do you mean by active? Physically strenuous? Or is it motion? Or is it a living, sensing, heart-beating, neurons-firing being? Am I inactive/passive when I am experiencing non-moving hands on my neck? Even when I am still, I am perceiving, processing and cells are in motion; and thus changing. The division between passive/active is for me no longer a valid one. I get massages on occasion, (because I CAN) and I can tell you that "just" lying there is a world of wonderful physical activity! A HVLA manipulation is also NOT passive.
Maybe we should focus more on what is "inviting" motion and what is "forcing" motion, then on active versus passive.
And what little I know of SC, it IS very active in a visible way.....

[Diane]

Mostly, I just sit there and let the nervous system respond to me being there. I've learned to feel it doing this, through my hands. It feels awfully active to me.

When people ask me how I can feel all this stuff, even just basic areas that need treating because of the tissue texture being way off normal, and me interpreting that as a choked neural tunnel, .. I reply that if humans can learn to read braille they can learn to read tissue, and I'm human, so it's not that big a stretch to learn to do sensitive manual therapy.

You can take whatever regular manual therapy you already "know", and finess it way down so that you are just hinting to the body at skin level what you would like to invite it to do; if the brain is in favor of the idea (after running it past all its processes for a few seconds) it will permit action to begin. It will come racing up to the skin to meet you. You will eventually be able to feel it correcting its own self. Suddenly you aren't capable (in your heart) of being coercive anymore. You've become interactive with this living creature buried inside human mesoderm, the 2% that is the nervous system.

[Bas]

You HAVE to write Diane. More. Wonderfully tactile and living description!
This is prose with a scientific flavour.
Wow

[Rolf-Inge]

Hi!
Thanks for your answears but the hole SC approach seems to be alittle like "healing" to me.I dont say that this approach might be of some help but how is the patient gooing to be participant iin his/her own "healing" prosess.
Arent you interested in prevented therapy?what the patient can do by her own,without our "healing" technics?
As you describe SC it seems to me to be an passive approch.Sorry Bas but im just a simple soul!

RIN

[Jason Silvernail]

RIN-
All movement comes from the patient, the patient's "home exercise" program is simply to find a place and time to practice ideomotion. There is no more active process than this.

We don't heal anything, the body does. We can only set the stage to let human physiology run it's course.

It is preventive in that it helps attune the patient to their body and to recognize the mechanical deformation of sensitive tissue before it reaches the critical [painful]threshold.

J

[Jon Newman]

RIN,

I'm currently of the opinion that this concept of preventive therapy for pain is a bit of an exercise in wishful thinking. I think we can, with some confidence, decrease the risk of a number of pathological processes and slow the normal degenerative changes life presents us but this is a bit different than "preventing pain the next time". It is at this point that I find myself departing from many PTs. On a variety of discussion forums I'll read the idea that the PT will help the patient (correct their alignment, manipulate them, use ultrasound, etc) this time and teach them (specific exercises usually) how to prevent it (pain) from happening again. I think this portrays an unrealistic predictive ability as well as a naivety on our part. At least to the extent that any specific exercises we prescribe are going to have some significant pain preventative powers. What is realistic, in my opinion, is to try to teach people how to manage pain once they get it (through education in pain physiology and movement strategies) regardless of how they end up where they are. With those skills one can move on--living life without trying to avoid all those things that someone told them cause pain or feeling obligated to a set of specific exercises to avoid future pain.

Simple Contact teaches people pain relieving strategies this time, right now and for their possible futures that neither we nor they can predict in a meaningful way.

Jason, how about this for a (feel good) quote of the week?
"We all labor against our own cure, for death is the cure of all diseases"--Sir Thomas Browne (I think)

[nari]

RIN,

SC is not easy to "get" by reading about it. I agree, it sounds like "healing" on the first glance - or twentieth..

Remember: The therapist does nothing. The patient does it all. We simply enable a way for the brain to get on with its evolutionary process of resolving a threat to its systems. It's pretty good at doing that...

We, as PTs, are so attuned to telling a patient what to do and how to do it and it's-not-the therapist's-fault-if-the patient-doesn't-do-it type of thinking.
This is a move away from controlling the patient and allowing instinctive resolution to occur. I think the patient's brain knows how to correct a dysfunction much better than any of us; we are not the patient's brain.

Movement is the key. Repetitive, specific exercise is not. A patient can go off and practise Tai Chi, swim, dance ,whatever...and still get better. But not every patient, as you well know, is going to do that.

SC is also a great way of enlightening a patient that this ongoing pain is not necessary, nor needed; and they can use it at home, whenever they wish to.
Sure, you can still do preventative physiotherapy for fitness and decreasing obesity, and so on. That does not disappear if SC is employed. Nothing else changes, if you don't want it to. SC can make our clinical life much simpler and attends to pain issues without any complex protocols.

Nari

[Rolf-Inge]

HI !
Learning people the way our minds(thinking-emotions)interacts with our body becomes more and more important for me than my tradiditional physiotherapy/manuellterapy approch.Its not about either or but the traditional MT technicks(manipulation,mobilisation,stabilization etc)dosent seem nesecerry any more.
The pain is interesting but the "man" behind the pain is even more intersting.
Its much more fullfilling to day working as an MT than 10 years ago.
Patients are much more intersting in this way of looking at their "painproblems" than just aiming at their pianfull area!To learn how thwi feelings interact with their body!
It might not be SC but it gives the patients and me A GOOD CONTACT.

PS!Have you dared to test the strenght on the left side?

RIN

[nari]

Hello Rin,

I agree that the person behind the pain/dysfunction is important, and whatever intervention we choose, this cannot be forgotten. It is undeniable that emotions have a crucial role in pain management (after all, it is thought pain IS an emotion) - I think the juries are out on its causing a pain state to arise.

In the end, we choose what we feel comfortable with; hopefully, as effectively as possible.

Re your left side hypothesis: no, I have not noticed what you have recommended for a long time. It doesn't mean it is not true.

Nari

[Synergy]

Chris,

Just read the info sheet for your patients and I thought it was great! I also found it helpful and the analogies you used were easily understood. Thanks!

[Jason Silvernail]

Wanted to share a good success with ideomotion and also put it in the context of "EBP"...

One of my partners is leaving the clinic, so many patients on her schedule were moved to me (and our chief, since I'm leaving as well in about 4 wks). This particular lady, 51 y/o female military officer, had neck and L upper trap area pain since JAN06, when a commuter train she was on derailed, and she was jerked about. She used her arms to stabilize herself, but says she felt the pain in the neck area shortly after the accident. No rollover or any trauma. She had the requisite Xrays and NSAIDs from primary care, and was sent to us. My partner treated her with what could be considered the best in EBP, and she simply was not improving.
Her findings on exam were cervical stiffness and hypomobility, especially "closing" L lower Cx facets and L rotation at the AA joint. Diffuse tenderness and "trigger points" in the cervical paraspinals on the left and the upper trapezius.
My partner had treated her with Thoracic manipulation, Cx joint mobilizations, AROM, and trapezius stretching, along with the deep neck flexor exercise. She was not improving, and my partner had moved her toward a general exercise regimen, with upper body stretch/strengthening and self trigger point massage.
She was mildly frustrated with her lack of improvement when I saw her, and my exam revealed loss of ROM of the Cx spine mildly in all planes, esp to L rotation, with only 45 degrees available. Her previously noted "joint" restrictions were also present, esp at the AA joint. Her ULNT was limited to about 60 degrees of elbow flexion before she had pain on her involved L side, and was mildly painful to her ULNT median on the R side also.
In supine, her L hip was internally rotated relative to her R.

We did about 5-10 minutes of ideomotion in standing and in supine, and she stated she felt better than she had in months. Her ULNT had improved to 15 degrees of elbow flexion on the L, no longer painful on the R, and her Cx ROM had improved to 65deg L rotation. Her "AA joint restriction" was no longer present. Her lower cervical "joint restrictions" were markedly improved. Many of her "trigger points" had disappeared. She reported all the characteristics of correction, especially a warming in her upper trap area.

I will see her back this week or next week (my last week in this clinic before my move) for a reeval.
I think I will be writing this up as a case report in the fall.

THoughts? Especially on improvement in the "trigger points" and "joint restrictions"??
:)

J

[Luke Rickards]

Jason,

I am always fascinated by the general direction people choose to move when they have obvious restrictions in a certain direction. You said your patient had an obvious closing dysfunction in the lower Cx. I am wondering if she chose more flexion or extension during movement.

I had a patient today with Cx pain and stiffness, only 40' R rotation, positive Spurling's to the right and pain on full flexion, with bilateral pins and needles in the ULs. In the seated position the head went into gentle extension which increased his pain considerably and reproduced the pins and needles and pain into his arms. I assured him he was in control and he stayed there for 10 mins, slowly increasing extension, which also slowly increased his pain. When he could take no more he told me and I asked him what he wanted to do about it. He then slowly moved into full flexion, which was now painless, for a couple of mins and when he came back up the pain was gone and R rotation was restored. So much for centralisation, hey!?

Luke

[EricM]

Great result Jason. In your post you describe the findings of a rather extensive assessment. Given so many findings changed post treatment, would you agree that many assessment procedures could be dropped from your evaluation? Which ones would you consider important to leave?

Eric

[Diane]

Just a quick interjection.. I would suspect that both Luke and Jason would need to keep their assessment procedures (and bother to do them faithfully) as long as they are planning to do writeups. Documenting in that sort of language will be best understood by all the mesodermalists out there who will need to be slowly herded toward neuroscience; therefore it will be necessary to maintain one's familiarity with this modern day dead language and ritual behavior.

[Jason Silvernail]

Eric-
Good question.
I think ROM, ULNTs, and any neuro examination (reflexes, strength, sensation) are really the important aspects of the examination.
However, as Diane points out, I need to continue to document the pre/post changes in these other findings to illustrate the concepts since that is a universal language among PTs and manual therapists.

Luke-
Though she had a "closing" dysfunction, she did choose to L rotate several times, but only after she had extended multiple times (without pain of course). Interesting in the context of our mechanistic manual therapy education, right?

J

[Barrett Dorko]

Perhaps you guys can appreciate how I feel about this recent exchange. I agree with each comment and have seen similar changes thousands of times. As Luke suggests, "centralization" ala McKenzie proved meaningless to me many years ago, as did many of the supposedly essential subjective and objective aspects of virtually every other form of manual care I'd learned in my long and passionate career in this field. Ideomotion (not Simple Contact) changed all of that.

Keep doing the documentation. Diane and Jason are certainly right about that.

I also presume that those of you who make any effort to predict or interpret the direction of the patient's ideomotion will find that this becomes useless. I also presume that Jason has discovered in this latest patient that the resting posture of the hips while supine is also extremely important to assess and assist toward appropriate change.

Am I right Jason?

[Diane]

"centralization" ala McKenzie proved meaningless to me many years ago, as did many of the supposedly essential subjective and objective aspects of virtually every other form of manual care Ditto that. In fact it meant so little to me that I never even bothered to learn most of it in the first place. I considered it a form of OCD.

[Jason Silvernail]

Barrett-

You are indeed correct about the hip position. I used to lay everyone down like that to assess/treat segmental mobility problems, but I think now I might start to do it to look at the hip and to start ideomotion. I'm not sure how often I've seen the hip IR, but it is quite common.

J

[Jason Silvernail]

I just remembered that I promised to give some feedback on the gentleman with "costochondritis". I did see him a few more times, and he was significantly better, but still painful. He has a lot of yellow flag work-related issues and psychologic issues as well, so I'm not sure how much more I can do for him, but his chest wall pain was significantly better after 1-2 sessions.

I had another lady today with a similar problem - chronic neck and arm pain with N&T who did not experience relief with any therapy (manip by chiro and PT, mobs by PT, neurodynamic treatment, DNF exercises for neck and even Cx mobilizations in the ULNT position (see attached paper). After 5-10 minutes of ideomotion, her ULNT improved and she was much better overall, with full painless ROM.

I attach the paper to illustrate the point that even the manipulators of the PT community are starting to understand concepts of sensitized nervous tissue and mechanical deformation. Interesting reading.

When I see what Ideomotion can do for people, it really gives me a new way to look at "Neurodynamics". I had read Michael Shacklock's excellent book before I got into ideomotion, and I confess to having mixed, but mostly no results using neurodynamic techniques in general. I am willing to admit this may have more to do with my execution of the techniques than the paradigm itself.
As I watch the changes brought about by ideomotion, I think "How could i have possibly choreographed this? What specific nerve could be responsible for these complaints?" Of course, no regimen of exercise or manual therapy treatment could possibly figure out how to unload the tissues as completely as ideomotion can. Maybe that's why I wasn't successful, maybe it is foolish for me to think that I know or that I can determine the motion or direction a given patient needs to achieve resolution or relief. Luckily for me, the patient's nervous system knows.

J

[Barrett Dorko]

Jason,

I could have written a post identical to yours long before the Internet was invented and it is truly gratifying to see that others (though very, very few) are having similar experiences after just a little time watching me demonstrate. When I teach these days the same thing alomost never happens, as far as I can tell, and I am left to wonder at the power of the therapy culture to resist any movement therapy that isn't choreographed. Maybe I'm teaching it that poorly. I don't want to rule out that possibility.

There might be a clue in your new avatar - the picture next to your post. Describing youself as a "sensible" vegan may imply that some of you guys are just a little too rigid, I guess. Maybe a "sensible" mesodermalist would similarly be one who hasn't lost sight of the many mesodermal problems that may exist in our patient population while carefully considering the possible contribution of an abnormal neurodynamic and our ability to self-correct (ideomotion) both unexpectedly and intricately.

I've more to say about Shacklock and Butler's tendency to think about these problems in a brilliant way but then to approach them manually in a way that I feel lacks a certain insight.

That will be a thread of its own. Stay tuned.

[Jason Silvernail]

Barrett-

You're right, many Vegans are anything but sensible. That's why the title needs to reflect that. If you're vegan and don't believe in chelation, homeopathy, chiropractic, and the evils of genetically-modified foods then you must be....a sensible vegan. I think the same thing can be said of those in the mesodermal world - I think there really are a lot of us out there who are beginning to look at the theory behind the practice and look for something else. I think the paper I posted is one such example of that. There are more "sensible" therapists out there who do think deeply about matters of practice out there -- I just need to find them. I already have a few on my radar screen, and I influence who I can. As do you.

J

[nari]

As the profession is so entangled with complex evaluations, I too think it is important to continue ROM assessments, etc. Otherwise they won't believe us.

In the few patients I have seen recently (all longstanding, complex pain people) there has been no sign of IR in either hip. I know it is common, which is why I am surprised. I have had no success with SC, as they have all 'fought' hard the idea of doing something without being told how to do it. They keep asking me for permission..not themselves. But sooner or later, one will 'crack' their self-imposed code. I know I am starting right down in the deep end of the therapy pool.

Nari

[Diane]

no regimen of exercise or manual therapy treatment could possibly figure out how to unload the tissues as completely as ideomotion can. I think working carefully from skin in can "unload the tissues as completely as ideomotion." I think this is a form of manual therapy, too. It isn't, however, as fast as ideomotion is. Nor does it contain the same degree of human primate social grooming satisfaction for the groomee. OK, or for the groomer either.

[nari]

In that same vein, I think that neurodynamics also completely unloads the tissues; it is reasonably rapid (in most cases) but it has the same drawbacks - it does not, at least in the beginning, allow patients to resolve the issues in the tissues themselves. It is still choreographed to a certain extent.

Maybe the zero role of the therapist is still an anathema to the general PT world.

Nari

PS I do like your cat, Jason - but then I am very biased with respect to cats....

[Luke Rickards]

Barrett,

I agree with your comment regarding prediction and interpretation, especially prediction which can even be conterproductive. Like Jason though, I do find the direction interesting in light of the standard mechanistic principles I was trained in. I'm sure the novelty will wear off eventually.

Luke

[Barrett Dorko]

Maybe the zero role of the therapist is still an anathema to the general PT world.



No doubt. When advising my students with regard to technique I send them to the Do Nothing (http://www.barrettdorko.com/articles/do_nothing.htm) essay on my web site but this doesn't seem to be helping much. Maybe I should emphasize that I'm speaking here about method, not study.

[EricM]

The breadth of my own assessments has narrowed considerably recently. I always observe the functional complaint. I like to look at balance, squatting, calf raising, general spinal ROM in standing, overhead reach, individual joint ROM if it is necessary to document such things. I suspect if I looked much deeper I would find other things, (lots of things probably) but I've come to realise that often these findings are secondary to the origin of the problem and are liable to change without any direct intervention. I've come to rely much more on general palpation, feeling for isometric contraction and tone.
Even during the subjective portion of the assessment I have caught myself acting more out of habit than reason. I often invite the patient to describe the quality of their pain and I'm starting to wonder why. It doesn't make much difference to me, pain is pain whether its burning or stabbing in nature. I suppose it gives the patient a chance to tell their story, to feel like they are being listened to. I wonder if interest in the many qualities of pain are just another construct of the mesodermalist approach, supposing different tissues would present with different symptoms depending on the nature of the disease. Another way to categorize everything. I'm rambling.
Sure simplifies my charting though.

eric

[Randy Dixon]

Jason,

I'm glad to see that you stated your conflict of interest at the very start of this thread, before your testimonials you admitted that Barrett bought you breakfast. C'mon fess up, you sold your soul for a bagel and a glass of orange juice, didn't you?

Given that you have had some success now with SC, and assuming that you will have some more, including patients in which prior EBP treatments were mostly ineffective, do you think you will start treating patients with SC prior to other methods? Does this change your argument or approach to the value of EBP or what exactly EBP is or should be? Obviously you would like to increase the evidence base for this treatment and similar ones, but since it is still scarce, how would you handle the skepticism, even hostility, of some of the "EBP" proponents to this type of treatment and the type of evidence backing it?

I guess I'm curious to see if this personal experience changes your perspective on the value of personal experience as evidence.

[nari]

Prediction can be misleading as it assumes all patients are equal in responses.
This particularly applies to McKenzie, despite the efforts to categorise and subcategorise their presentations.

Eric, the emphasis placed on the nature of the pain seems a bit irrelevant to me also. It can help with diagnosis, but in a quite limited way, and still is a mesodermal approach.

I listened to a pain specialist today when we were discussing an unhappy lady with "fibromyalgia" with muscle spasms in her legs and burning feet. He said unequivocally they were totally unrelated because they were different systems.
Aarrghh.

Nari

[Barrett Dorko]

Randy,

Your presumption that Simple Contact is not evidence based is misplaced. There's plenty of evidence that movement is needed to resolve the abnormal neurodynamic. All Jason's done is allow the patient to pursue that movement actively rather than passively. For the hundredth time, if someone's definition of EBP is only that it's been demonstrated to be effective then they are doing the term a disservice, to say nothing of their absence of clinical reasoning.

It would also be a good idea to separate Simple Contact as a method from idemotion as a movement therapy. The former is just a name given my personal approach and the latter is simply a natural process of recovery from mechanical deformation normally inhibited for a variety of reasons.

Nari and Eric,

I agree that the "quality" of the pain is virtually meaningless as a finding or as something that drives care. When it comes to an abnormal neurodynamic location doesn't mean much either. Intensity, duration and frequency are aspects of the patient's experience that I use to assess progress but they don't tell me what I should do.

[Jason Silvernail]

Randy-
In the interest of full disclosure, it was more than a bagel and orange juice, there were fried potatoes with onions and blueberry pancakes, and a breakfast bar. I wouldn't even write a paragraph for just a bagel and juice. If I'm going to sell my soul, it will at least be foran unlimited breakfast buffet! :)

Seriously, though, I appreciate your questions, and I know that when you're talking of evidence, you're talking at the patient-outcomes level. This is the reason I wanted to bring up the context of EBP here -- because I'm a proponent of it, and because when I did the reading I found that ideomotion has quite a bit of evidence behind it - just not at the patient outcomes level. In that regard, it has quite a bit in common with many other common interventions in PT, and to it's credit it has a much more sound theory.

Your questions are insightful as they illustrate the paradigm shift I'm going through right now - and I don't quite know how it will all sort out just yet. But you can be sure I'll be talking about it here.

I think that my particular situation in the Army calls for the treatment of a fair amount of pathological problems that I am rehabilitating - knee osteoarthritis, chronic tendonopathies (rotator cuff, achilles, patellar), post fracture and postoperative rehabilitation, etc. So there's a sizeable portion of my caseload that does not by definition involve the consequences of an abnormal neurodynamic. Though, as we've discussed earlier in this thread, often it can happen in more "orthopedic" cases as well. So for the orthopedic type stuff that involves tissue pathology mostly, my practice probably won't change much.

For those with back and neck complaints, however, I think this transition will be much more difficult. I think especially the lumbar stabilization issue is keeping me up at night. I was a strong proponent of this mode of care for a long time, teaching other therapists and patients the "local" muscle approach for spinal stabilization. This makes less and less sense to me as the weeks go on, but I'm not sure exactly how I'm going to address it in practice. I still do spinal manipulation for those who fit the lumbar prediction rule, and occasionally in others. I think right now most of my success with ideomotion has been with cervical/thoracic and UE neurodynamic problems, so there's no doubt that colors my choice of treatments for particular areas of pain. We'll see how the evolution goes, trust me I'll keep everyone posted.

J

[Jason Silvernail]

I saw the patient I talked about in Post#70 back today. She is doing better than before the last visit (her first with ideomotion) but not quite as good as after the last session, when she felt so good.
Her TTP around the L trapezius is improved. Lower Cx facet joints are still hypomobile, but improved from last visit. Her AA rotation is still limited to the left. Her global ROM is good, with pain into extension and full flexion, but symmetric rotation to 70. Her ULNT median is at 45deg elbow flexion.
Her L hip lies in relative IR again today in supine, and her apical breathing has returned, she says she's stressed at work.

Ten minutes of ideomotion in sitting this time, b/c she says she wants to get it going at work better, and she mostly sits at work. She does repeated small circles with the neck, no probing of the range of movement, no shoulder or shoulder girdle movement despite tactile "suggestion".

After therapy, her hip is almost into full ER in supine, her lower cervical and her AA motion are completely symmetric and painfree, ULNT median to 10 degrees elbow flexion. Her "trigger points" seem to have resolved.
Remember on the first day her ULNT was at about 60 degrees, and her Cx spine was "hypomobile" and painful.

She's very happy with the progress. So am I. Thought I'd share.

J

[Barrett Dorko]

Jason,

Sounds like you're doing fine. I'd add the ironically titled "Improving your sitting posture" exercise I developed from Feldenkrais you can find at the back of the course manual you have.

Not that you seem to need any advice at all.

[Randy Dixon]

Randy,

Your presumption that Simple Contact is not evidence based is misplaced. There's plenty of evidence that movement is needed to resolve the abnormal neurodynamic. All Jason's done is allow the patient to pursue that movement actively rather than passively. For the hundredth time, if someone's definition of EBP is only that it's been demonstrated to be effective then they are doing the term a disservice, to say nothing of their absence of clinical reasoning.-Barrett

I think that if you re-read my post you will see that I did not make that presumption. The direction of my thoughts was closer to your final sentence, although I was more curious about Jason's thoughts than expounding my own. Ideomotion/SC, in my opinion, from what I have read from you and others about it, is evidence based, but not Evidence Based. Using the levels of evidence that EBP uses, the evidence isn't strong supporting or refuting it. This area, EBP and empirical observtion, continues to be of interest to me because of my own difficulty in reconciling different approaches. The best course seems to rely on something as subjective and non-enforcable as "good judgement".

[Barrett Dorko]

Randy,

Did you come up with this definition of "evidence with a capital e" on your own? I've never encountered it before.

Your careful consideration of empiricism and evidence isn't a bad idea, but it lacks something essential - theory. In the past you've spoken of your wife's enthusiasm for Iam's method. If you look for a coherent and defendable theory there, to say nothing of the work's construct validity you won't find anything.

In this way Iams and the manipulation advocates are making the same fundamental error "alternative" approaches have made repeatedly for many years now; No Deep Model (http://www.barrettdorko.com/articles/no_deep_model.htm).

[Randy Dixon]

I agree that Iams fails to make any serious attempt to explain the theory behind what he does. My wife's enthusiasm is for the results the techniques have provided. She has terminated her instructor status due to the lack of explanation of his theory and his marketing techniques, and I am persona non grata because of my questioning done at his email forums and my comments on RehabEdge about PRRT. On the bright side, if my wife, as a PRRT practitioner, has a patient that doesn't respond to her treatment, she is welcome to refer to John Iams himself for the remarkably low price of $500/hr. This may sound like a lot, but you can save airfare because he can provide this service at the same cost over the phone.

As to the capitalized Evidence Based, Evidence Based Practice or Evidence Based Medicine is the title of a proposed theoretical model of practice. As a title it is capitalized, but not all evidence based practices are Evidence-Based practices, just like not all practices that use simple contact use Simple Contact.

[Barrett Dorko]

This all sounds like a good reason to get rid of the term "evidence based."

When I first heard it I felt it implied that the standards of science were applied there and nowhere else. That turned out not to be true. Then I assumed that the "evidence based" practitioners were very concerned with the quality and nature of the evidence they cited. Then that turned out not to be true. Then I figured that I would be included because of my often-stated opposition to "alternative" medicine and was publicly called "a reckless liar" by the APTAs favorite EB practitioner and researcher.

At this point I'm happy to describe what good evidence would consist of but I'm not going to join the little club my profession has formed.

[Jon Newman]

I wonder if a guy could get capital E evidenced based medicine trademarked? They'd either make a million or significantly reduce the number of people able to use the term as they desire. I noticed that more descriptors are added to the definition as the term matures. I wonder if they'll eventually simplify the definition of EBM to "the type of care we used to provide."

[Jason Silvernail]

I think like any movement, EBP will have it's growing pains.

Reading some of the stuff in the British journals is funny, as they seem to have a dry sense of humor about how the term gets interpreted differently over time.
I think we could all agree that critical review of what we do and why is a good thing. I think we can all agree that there is senseless practice variation occuring across several professions, and fixing this is important - not to make everyone the same, but to put them all in the same ballpark at least.

Positive Things EBP has Done:
1. Started teaching in our students the importance of critical appraisal and some basic skills to do so
2. Placed focus away from techniques and more on to clinical reasoning and evidence
3. Marginalized many of the more questionable practices in therapy, at least on paper
4. Given us a paradigm of thought to use to guide decisions
5. Stated in it's orginal definition (via Sackett) the importance of patient values and clinical experience

Negative Things EBP has Done:
1. Some groups develop a narrow view of what kind of evidence is acceptable, and claim that practices/groups not in accordance with that are unscientific.
2. Sometimes presented in a vague way so that some groups/practices consider anything typed on a piece of paper as evidence.

So, I think we all have a lot more growing and changing to do as a profession in terms of integrating this into our practices. I believe it's too early to determine what effect it will have in the long run. I have seen, for my part working with students and practitioners, far more positive than negative.

J

[Gil Haight]

The origin of EBM as I understand it has four arms of consideration
1) biological plausibility
2) clinical prediction rules
3) identifiction of adverse effects
4) RCTs
It seems to me that most at this site are interested in the biological plausibilty aspects. If this is violated , none of the others are relevant. It is amazing to me how those at the top of our profession simply choose to highlight 2 & 4 over or even to the exclusion of 1 & 3
Gil

[Barrett Dorko]

Good point Gil.

The major mystery to me will always be my professional association's lionization of those who have done exactly as you point out. What happened there?

[nari]

I certainly agree with Jason and Gil's points. Nicely encapsulated.
From what I have noticed, online and off line, the critical points for most PTs seem to be 2 and 4, as already pointed out...because they are probably easier to understand.
It is rather like the manipulation /core stability squabbles; Gil's #1 point gets forgotten in the stampede of practising according to what someone else has dictated...or most importantly, what they thought was being said.

nari

[Jason Silvernail]

I saw the patient in question yesterday, who I wrote about earlier.

She came in feeling stressed and still her pain had not changed a great deal, but admits to not practicing the ideomotion as much as she could have.

When I saw her yesterday (third time), her Cx joints including her AA were hypomobile, but still not as much as the previous time. Her ULNT median had her elbow at about 20 degrees.
Five minutes of ideomotion later, no more AA hypomobility, dec tenderness to L neck and trapezius, and ULNT to 5 degrees elbow flexion. Parasympathetic shift, etc.
I'll have to do a phone or email followup with her in a couple months to see how she's doing, since I'm moving soon.

She really seems to know how to control the pain, but she asked me some questions that I thought were interesting. Immediately after doing the one thing that had worked immediately for her, she asked me if she should seek massage or chiropractic (read: manipulation) care. I told her that either rubbing the muscles or manipulating the neck "might" make her better, not change her pain, or make her worse, including some people who are dramatically worsened with manipulation of the neck. Whereas the ideomotion could not by definition come from anyone but her, and had already made a big difference. Overall, I left that decision up to her, I encouraged her to seek what care she wanted but gave her my opinion about why I thought it would not be helpful. Interesting. I thought especially interesting her question re:chiropractic, since she had said specifically she did not want manipulation of her neck, that the cavitation she had during ideomotion bothered her, and she had had Tx manipulaiton and Cx mobilization in PT already, with minimal to no results. I realize that this last bit is more interesting in terms of how people respond to treatment, and not really about ideomotion, but it's pretty funny overall.

I thought it was funny that she started really asking about different care once she started getting better, and I let her know that corrective movement was all the treatment she needed. She didn't ask for more care when the treatments were painful and not helping, ironically. Maybe people just want to have things done "to them" after all. I guess I should also mention that I think she has litigation pending with the commuter train line. :rolleyes:

J

[Barrett Dorko]

Jason says, "I thought it was funny ..."

Funny? Are you sure?

I don't often do this but I'm going to use some leverage acquired from decades of treating patients to say this: Within the context of her care and your description of her response her comment can mean only one thing for sure - You're a dead man.

Kind regards,

[Luke Rickards]

Maybe people just want to have things done "to them" after all.
Jason,

I think there is truth in this, even if nothing is done to them. I know of many cranial osteopaths who see 60-80 patients a week (everything from the most minimal aches and pains to unresolving chronic problems) that come week after week to lay still on a table while someone gently holds their head or sacrum.

It seems that the need state is complex and often requires more than corrective movement for resolution. I think many patients place the 'ritual' of therapy before the content, and perhaps the ritual of going repeatedly to any practitioner that touches you helps to fulfill some part of an ongoing need state for people in the modern environment - especially if the ritual never actually adressess the corrective movement part of that need state.

Luke

[bernard]

Explore (NY). (javascript:AL_get(this, 'jour', 'Explore (NY).');) 2006 May;2(3):216-25. Links (javascript:PopUpMenu2_Set(Menu16781644);)
Neural and cognitive basis of spiritual experience: biopsychosocial and ethical implications for clinical medicine.


Giordano J (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Giordano+J%22%5BAuthor%5D),
Engebretson J (http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_AbstractPlus&term=%22Engebretson+J%22%5BAuthor%5D). Center for Clinical Bioethics, Georgetown University Medical Center, Washington, DC, USA. jgiordano@neurobioethics.org
The role of patient spirituality and spiritual/liminal experience(s; SE) in the clinical setting has generated considerable equivocality within the medical community. Spiritual experience(s), characterized by circumstance, manifestation, and interpretation, reflect patients' explanatory models. We seek to demonstrate the importance of SE to clinical medicine by illustrating biological, cognitive, and psychosocial domains of effect. Specifically, we address where in the brain these events are processed and what types of neural events may be occurring. We posit that existing evidence suggests that SE can induce both intermediate level processing (ILP) to generate attentional awareness (ie, "consciousness of") effects and perhaps nonintermediate level processing to generate nonattentive, subliminal (ie, "state of") consciousness effects. Recognition of neural and cognitive mechanisms is important to clinicians' understanding of the biological basis of noetic, salutogenic, and putative physiologic effects. We posit that neurocognitive mechanisms, fortified by anthropologic and social contexts, led to the incorporation of SE-evoked behaviors into health-based ritual(s) and religious practice(s). Thus, these experiences not only exert biological effects but may provide important means for enhancing patients' locus of control. By recognizing these variables, we advocate clinicians to act within an ethical scope of practice as therapeutic and moral agents to afford patients resources to accommodate their specific desire(s) and/or need(s) for spiritual experiences, in acknowledgement of the underlying mechanisms and potential outcomes that may be health promotional.
PMID: 16781644 [PubMed - in process]

[Jason Silvernail]

Barrett-
I knew you'd respond that way. I felt the same way.
I don't mean funny like "ha, ha", I mean funny like "sad".

Luke-
Brilliant point. Agree completely.

J

[Diane]

A theme Chris touched on when he brought up "Flow" made me think, really think, about the whole problem we have with PT having evolved as a culturally specific form of health care, along with most of the others, without good biological foundation (i.e., embryology and evolution), therefore rudderless. Although I've tried to grow myself a rudder, the profession lacks such a thing collectively.

The thing that unites all forms of culturally specific forms of health care (chiro, osteo, massage (the million kinds that exist), PT, etc etc. and the multitude of techniques named after individual originators who came out of the woodwork, Rolfing, Bowen, all these.. maybe we could include medical attention and nursing care too, psychotherapeutics need to be in here too, virtual social grooming) is that all are variations on the underlying theme; there will always be people who feel best when able to access social grooming of some sort ... because we are primates. Let's just admit it. I think the reasons we continue to maintain these behaviors within our human cultures run so deep as biological instincts they blur right over into being psychologically deep as well.

The whole point of the interaction, the therapeutic relationship, is to get the right placebo reponse (in the Patrick Wall sense) started. All forms of health care are therefore veiled forms of human primate social grooming. All forms of human primate social grooming have rituals associated that differ enough to form actual separate treatment subcultures. PT has been broad enough to umbrella itself over most of them, and aware enough to give itself the task of eventually understanding what they are about, and adhering to science-based principles in the process.

So how could we have missed this substrata of self-understanding? OK, lots of it wasn't around or defined yet when we initiated the profession a hundred or so years ago. But I think our profession should take evolution into account the way it should any science-based body of knowlege, not turn it over to the shadow side of our collective awareness as a profession. We can't let ourselves stay locked into quaint and anachonistic and sanitized mindsets while the rest of the culture, the whole of science, has moved on.

Social grooming began as an animal activity, e.g., mammal mothers licking their pups/kittens/calves etc.. primates took it further into wider social arenas, intra-troop behavior.

We got our big brain because of sociability in the first place, according to primatologists, to keep track of who's who and to keep the peace; as humans we have the most complex kinship patterns ever analyzed. This is how it looks to me right now: the initial bonding that goes on between humans (e.g. parent/child) needs to be reaffirmed artificially once in awhile, as in, when there is a period of personal chaos or growth, which may or may not include physical injury. What we know for sure is that physical injury is certain to knock one off one's tracks for awhile; how it is handled socially can be/often is pivotal to good resolution.

If that's all true, then good old, non-nocioceptive/unresolved 'pain', physical and/or psychological, is a need state all right, but a need state that requires consummatory movement on a spectrum that might range from:
1. just learning to practice some creative motor output (see Barrett Dorko),
2. further along to active physical relating e.g., hugging/sex with a partner, (stay away from therapists)
3. way over to the far end of the social spectrum to boundaried input of a physical sort from a therapeutic 'stranger'.

In this third case the bond inside the patient, their intrapsychic balance, perhaps the bond they have with life itself, can only be restored through physical human contact, from outside the immediate family. I think this is so fundamental that everyone just ignores it completely.

As Barrett has pointed out there are social groomers out there who because of human belief systems, won't entertain the possibility that we evolved at all, let alone evolved instinctively doing this merely because of how healthy it feels, both for the groomer and the groomee. (OK, manipulation is likely more of a latecomer on the social grooming scene. I haven't read any accounts of primates in the wild cracking each others' spines.)

The truth (and I think this is true) sucks, doesn't it? It adds no glamour at all to our profession, makes us humble, puts us in our place at the bottom of the health care hierarchy. Yet, when I ponder the thing from another side, as one who instinctively moved toward this type of work when I was still a child (driven by overactive mirror neurons perhaps), it feels real and honest by comparison with lots of other human activity that goes on that is greed-based and disgusting and destructive. I still can't imagine anything in the world I'd rather do for a living, but restore/keep the peace, one human body at a time, and my own in the process.

[Barrett Dorko]

Jason,

My son Alex has also been known to say, "I knew you were going to say that," and I never sensed that it was any sort of compliment, but I don't mind at all. It means you know me - even my eccentric and mildly irritating ways.

When did I become so transparent?

Diane,

Thanks for that last post, I think. Both true and painful to acknowledge. This, I think is a large subtext of the Soma Simple site. No wonder so many only visit once.

Anyway, it occurred to me that the tendency I have to an affinity for if not an actual attraction to Asperger's Syndrome (http://www.barrettdorko.com/articles/with_death_comes_food.htm) makes me the kind of therapist I'm compelled to be. After all, my mirror neurons don't guide me as they do others, theoretically anyway.

Has our primate status contributed significantly to ineffective manual care? Is the future progress of our method dependent upon dispassionate, relatively non-empathetic approaches to the patient in our hands? Isn't this the opposite of the attitude sought and encouraged by the academics when they allow students to enter therapy school?

[Diane]

Has our primate status contributed significantly to ineffective manual care? Our human primate status has likely contributed to our capacity to kid ourselves, deceive ourselves with outlandish belief systems, allow our brains to rewire our belief systems into the emotional/ threat perception pathways, then try to enforce them as truth. As if they were something real.

Is the future progress of our method dependent upon dispassionate, relatively non-empathetic approaches to the patient in our hands? No, I think there's too much of that already. By the same measure, sentimentality has no place.
Isn't this the opposite of the attitude sought and encouraged by the academics when they allow students to enter therapy school? I have no idea.. how did our work get so puffed up/ when did we get so puffed up about it that it needs to be a doctorate program? wait a minute, I do.. human primate foible. And precedent. Chiros leaping around like baboons started this trend way back when.

Academic programs are artificially 'selecting' human primate social groomers to try to make sense out of the profession, help it 'evolve', while deliberately damping down the understanding of any deeper model of how we might actually be connected with our own species enough to want to take on the profession and work at it steadily, deepening into it. The way that looks to me is that the whole activity of HPSG, human primate social grooming (inherited, organic, functional, natural) splinters into a jillion superficial pieces that are just stuck on the outside of whatever human culture with no depth or real integrity. Yes, human culture, the human troop, needs HPSGs.. and some of us, for whatever reason, are drawn to the work, but trying to understand why takes us into scary places and backward into our own evolutionary history. Most people are coping by just deciding, Let's avoid any talk of evolution. Let's just create a new belief system/adhere to any old one with which we can comfort ourselves, cheer ourselves up, move on with the rest of the troop. Act like we're cool, hip, smart, up-to-date. Become "D"HPSGs.

Be careful when you start to take on trying to fathom ectoderm (http://www.mona.uwi.edu/fpas/courses/physiology/neurophysiology/INTRODUCTION.htm), it's very powerful stuff to study (http://books.guardian.co.uk/departments/politicsphilosophyandsociety/story/0,,1832509,00.html). It will take you to truth, and truth can be bitter even though it is the very best medicine, like paint stripper for illusions.

[EricM]

Diane, do you paint? Your last two posts are like works of art. Two of your best ever, I think. Thanks.

eric

[Luke Rickards]

She does paint.

I've seen them, they are beautiful.

[Jon Newman]

Diane, at the beginning of those posts you should encourage people to place some thera-foam on the floor to protect their jaws as they drop.

Rock on.

[BB]

Diane,
You're post is huge. Wicked huge if we were in Boston.
I've been thinking for a while now about patient expectations and how frustrated, or let's be honest, pissed off I get when I give what I feel is a very thorough and effective treatment and the patient stands up, looks disappointed, and says "I thought I was going to get a massage." My patients seem to come in with a combination of the following expectations 1) pain relief 2) they will get exercised to the extreme and need a no pain/no gain attitude or 3) they are going to get a massage or ultrasound. This is not counting nocebos of course.

The group who expects to get number 3 is often dissapointed by me, because I do not meet that expectation. Number 2 is often relieved so there is not a problem there. Number 1 hopefully will find what they were looking for.

The grooming that is expected of me then seems to come down to 2 camps, relief and pleasure, often times presenting as a combination. Those expecting relief through pleasure seem to be the ones that fire the "pissed off" reaction from me as stated above. I wish it didn't get to me so, but it does. It's kind of an "oh crap" moment.

So, my question is: How do we handle those patients whose need state for correction has been met, but their need state for social grooming has not? Jason's gal is a great example.

[Diane]

How do we handle those patients whose need state for correction has been met, but their need state for social grooming has not?
You know, I've not ever tried to separate the "need state" into these two things. Good social grooming takes care of both the pain "need state" and the "need state for correction." Simultaneously. Doesn't it? Works for me, anyway..

From the first session I teach patients how to refrain from "needing" me, by finding out about them, helping them find awareness, be in a body better, learning to watch their own movement behavior or non-movement behavior, favorite lounging positions etc.. asking them to change ends of the couch or lean on the other elbow or cross the other leg or sleep on the other side.. education education education about pain, brain, nervous system, show them lots of pictures of nerves... I contain the encounter, make it a short term relationship, teach them to fish instead of coming to me to buy a fish.. all that stuff. But I touch touch touch them, pull their skin this way and that, move their arms and legs, get them to feel their physicality better so that their physicality (or at least the part of the brain running it) can learn to feel better.

Works for most people. I'm learning to read those flags better however...

Like the new red flag lady today who announced in the first sentence out of her mouth that every laceration she has ever had has been painful to touch ever since. Uh-oh. Hypoglycemic, viral infection, frequent pain across the chest, has had every neurological test under the sun for pathology to account for her face and eye drooping when she gets tired, only on the right side. She went home with the explain pain book and no touching, but a whole hour of talking, pain education, questions answered as best I could, and a plan to begin by treating (skin only) the non-allodynic neck that she injured age 20, twenty years ago that still hurts so much that she has to lift it with her hand to roll over at night, but not in the skin so much, and the tendonitis in both arms.. before we can get to the recent parrot bite on her finger that hurts her because she's a keyboardist, and was what brought her in.

Like the new yellow flag lady today, who is older, a Ukranian WWII war orphan, shuffled around by occupation captors, horrid life, no one has ever listened to her, tons of resentment, bitter and sad, pain in every part of herself, rigid body, neck, a hard rock where her thyroid should be (which could be a red flag in and of itself), on a bunch of meds for high blood pressure and tachycardia, no time to treat her yet, not even in a whole hour session, but got a bit of a look at her range, got pain education in, got a plan, developed with her, to begin with her head and neck and knees.. and to keep my ears open, let her vent, let her destress, keep the kleenex box closeby, let her nervous system do whatever it needs to do.

Both these women need a lot more social grooming than most. But they likely won't need more actual time or number of sessions, once we get rolling; I really think it's all in how you listen in that first session, and reflect back what they've said. And how easily you can find an extra bit of compassion from somewhere inside to help you listen better when the story is sadder or harder to listen to.

Sorry J, didn't mean to high-jack your thread.

[BB]

You're recommendations on boundary setting on the initial encounter are well recieved, and are great advice. I think we may not be talking about the same scenario yet though.

Well, I'll give an example. My wife comes home from work with a sore back occasionally. Recently she asked if I would work on her back. I worked through her skin to knock down any cranky areas I found. I then rechecked her painful motions and did some awareness increasing movements with her. When we were finished, I asked how her back felt and she replied, "well, fine for right now." I asked "what do you mean." She replied, "well, I thought you were going to rub my back." In other words, she was telling me that I did not meet her expectation despite the fact that her pain was gone.

Now, given this is a husband and wife interaction which changes the dynamics quite a bit. But this is not very different from what I've heard in the clinic time and again.

Now, I owe you a great big thank you Diane, because working through skin with integumentals tends to meet this expectation better than my past, way more hands off, approach (I actually owe you many thank you's for how you've improved my practice). But, as evident with my wife, it still occurs. Most often, the expectation is planted by the referring doc, who tells them "Go to PT. They do exercise and massage and ultrasound."

You know, I've not ever tried to separate the "need state" into these two things. Good social grooming takes care of both the pain "need state" and the "need state for correction." Simultaneously. Doesn't it? Works for me, anyway..

I guess here I'm curious if we are looking at 2 different need states that are often consciously confused by us human primates. Just as there are different need states for hunger and sleep, so could there be need states for pain and social grooming for pleasure. Social grooming could be used to satisfy both, but the need states could be different. My wife seems to have had both need states. She told me she wanted one satisfied, but really wanted the other.

I hope I'm making sense. Help me get past my sympathetic nervous system trigger!

[Diane]

Cory, if she were my wife, I'd have said, "Well, why didn't you say you wanted your back rubbed in the first place? Not my bad." ;)

I think you have to be clear up front with patients that this will be different than massage, that I'll be working with their nervous system not their muscles. I ask them if they've had other kinds of treatment, usually they've had massage for years, but still have pain. (Often it will be their massage therapist sending them!)

I agree that people get a different sort of social grooming hit from massage therapy. It's more ongoing, they have a tighter relationship with more confidences, more talk about broader social issues, different sorts of boundary issues. More like a hairdresser type thing, or the people that cut toenails and take off corns, regularly for years. I don't worry about it, just explain to them what I do, how long it will likely take/how many sessions usually, confirm that they're coming to see me because they want the pain gone and that the relationship is not expected to be ongoing, that I don't care who else they take their body to see or have done to it with the glaring exception of neck manipulation.

[BB]

I did tell her that. Wasn't well recieved. I told you, it is a sympathetic burner for me. So, not a moment of marital bliss, although I didn't have to sleep on the couch. Should have kept my mouth shut and came straight to you guys to complain about it. The doghouse here is virtual. You thought I wanted this solved for help in the clinic didn't you?:D

[Barrett Dorko]

I don't think the thread has been "highjacked," I think that like many it has simply begun to weave, and in this case in a wondeful way.

Distinguishing the need for social grooming from correction is something I hadn't previously considered but doubt I will now ever forget. I think this is important information for every clinician, especially one such as myself.

My limited capacity toward the provision of such a need (social grooming) means that I'm not going to waste that sort of time on strangers (patients) and will instead reserve what I have for my family and a tiny group of friends, most of whom are hundreds of miles away. My focus then becomes correction of mechanical deformation, not small talk - which I generally loath. Most therapists, as far as I can tell, aren't like this. Do you suppose this is consequently reflected in their choice of technique? How could it not be?

There is the issue of initial boundaries here as well. I don't make any speeches about such things but people seem to understand what I'm about via my non-verbal mannerisms. If they don't see that and mistake me for the sort of therapist that can be told how to practice by any patient I have a look that dispells the notion in short order.

I learned this from my mother.

[nari]

Interesting...

Most PTs are much better at small talk than I am, and I had the feeling my patients sensed this fact. In other words, they didn't really expect social grooming after the first five minutes. Could be hopelessly wrong here; maybe it's something else.
But if social grooming is the main subtle reason that most patients attend and this aspect is satisfied, there may be more compliance with what the PT wants them to do. (NB - we are talking traditional therapy here).
So it could well be that there is a relationship between techniques chosen and the level of chatter; the greater the small talk, the more gear, gadgets and scary posters in the room and the greater the likelihood of toolbox usage.

Anyone fancy a survey (informal of course) on this enlightening fact? ;)

Nari

[Jason Silvernail]

I agree with Barrett, no highjack at all, just a good turn.
I think there's something about working with ideomotion that makes this dichotomy between need states more stark, I think it's the minimalization of therapy that really brings that out.

It is all about expectations, isn't it?

J

[Diane]

OK then, no hijacking has taken place.

So, I think this still holds:
All forms of human primate social grooming have rituals associated that differ enough to form actual separate treatment subcultures.
There is some sort of scale maybe, wheremore specialized forms like dentistry or medicine that have to handle the CNS in intense ways, blur away and out into other forms that handle the CNS in 'pleasurable' or patient-driven ways that include chitchat like hairdressing or spa visits.

I guess PT in general must be a bit further along toward the closemouthed end of the scale of social grooming; massage therapists would be on one side of us and people like dentists on the other, who don't include chitchat due to the fact their patients are rendered speechless, punctuated by the the occasional openmouthed "Uh!", for long periods of time.

Chitchat is one thing, but giving patients the space to unload their angst if they want to/have to is another. I think we likely all try to be as adaptable to our patients as we can, and still be in our own most effective comfort zones. Barrett might be flexible by a couple degrees only, I'm probably able to give them more leeway, up to (on my imaginary goniometer of permissible verbal patient interaction) maybe 20 or 30 degrees.. Nari probably more, up to 60 degrees or maybe as much as 90.. certainly not 360 like psychotherapists or 180 like massage therapists. But I don't think dissociated chitchat about football games or what to make for dinner, or peoples' endless preening chatter about their children and families has a place during treatment time. Especially coming from the therapist.

There is certainly a bit of an art to allowing patients to direct some of the conversation.. let them have a sense of equal particpation or teamwork without letting them have complete control; stay focused on the task but let them approach and retreat from it enough to get a sense of where their anxiety level might be set. It's all CNS, every bit of it.. it's they who need to become interested and involved to the point of changing their own brains, and no two are exactly alike. It's like martial arts.. being very observant without looking as if you are, "taking advantage" of every slight opportunity to persuade that CNS that there is no threat, both mentally and kinesthetically.

[nari]

I'd probably be sitting around 40-60 degrees, and with some patients, they speak 20 words to my one. But if they are not useful words, relevant to their story, I steer them away to other 'threads'.

I have been taken to task before (nicely) about no hands-on for 20-45 minutes while verbally engaging the patient's CNS. Somehow this is seen as not appropriate 'physical therapy'; but I have never been good at adhering to a label that has been stuck onto me simply because I went to uni for several years to learn about the body. At the end of such a session, the patient's demeanour, colour, smile status, pain reduction and more fluid motion tells me this is physical therapy - it is not massage or mobilisation or twitching and twanging muscles - but enabling better function, nevertheless.

And, I vaguely suspect, though others might disagree somewhat, that a form of ideomotion had occurred. I didn't see it in the form of nonconscious movement or with the usual signs, because this was preSC days. But a positive something happened that seems to be corrective without evaluation or re-evaluation, or any kind of physical contact.

But, it may have been simple social grooming. Perhaps the two cross over at some point.

Nari

[Diane]

At the end of such a session, the patient's demeanour, colour, smile status, pain reduction and more fluid motion tells me this is physical therapy Exactly! I didn't mention this before, but I will now because it supports this idea.. The yellow flag lady I wrote about a few posts up relaxed her shoulders when I told her she would be able to talk about whatever she wanted to talk about during her sessions. (I expect some of it is pretty brutal.) I had done nothing to them. I wasn't touching them at the time. I was sitting on the bed and she was sitting on the chair. She felt her own shoulders suddenly relax, all by themselves, and commented on it in surprise. Cool stuff, this CBT.. setting up a container for it.. letting people know they can be safe, letting them feel that way.

[Jon Newman]

From the Hawks and Doves article in the EVOL thread (http://www.somasimple.com/forums/showthread.php?t=2685) (Korte, Koolhaas, Wingfield, McEwen)

When the environment is safe (e.g. no predators present)
extinction of passive avoidance, via a MR-mechanism [175]
and extinction of active avoidance, probably via a brain GRmechanism
will take place [176]. However, when the
situation remains unclear fear potentiation may take place
via a GR mechanism

[Randy Dixon]

I think along the lines of Diane on this issue, a patient does come in bringing only their physical body, they bring themeselves, every bit of themselves. The distinctions between psychological, emotional and physiological needs aren't neatly compartmentalized as we might like them to be. Validation, acceptance, understanding, are all needs that people, particularly those in pain, carry with them, it is not unreasonable that they look to a therapist to partly satisfy those needs, and in many people the therapist may be the only one that has shown any interest or availability to provide for those needs. Simply touching someone provides a relief valve for some of these needs, it begins a process and may be sufficient for some people but insufficient for others. I think therapists approach this in different ways and with different aptitudes. Barrett may provide acceptance and understanding by a non-judgmental touching, while Nari does the same thing with talking. Either one may be preferable to some patients while being frustrating to others. Also, while elimination of a negative is good, it doesn't eliminate the desire for a positive.

Cory,

My wife almost refuses to treat me and for largely the same reason as you describe. I have a couple of questions that I thought about regarding your post. Why do you think you get angry when patients, or your wife, responded that way? Expectations? They/She had expectations of you, but you also had expectations of them. Obviously, it also is a bruise to anyone's ego. Do you think that if there were a machine that could do the exact physical acts that you do would the treatments be as effective? Satisfying?

On another similar note, I've never understood the way some therapists seem to almost take pride in refusing patients what they want or ask for. Besides practical considerations, time, energy, reimbursement, why would you wish to deny a patient something they believe would help them? I can understand Barrett's answer that some patients expect things that he isn't really capable, either by training or by nature, to provide but I have heard therapists declare things like "I know she wanted me to rub her neck for a couple of minutes, but I'm not going to do it" as if this would be an ethical breech.

[BB]

Hi Randy,

Why do you think you get angry when patients, or your wife, responded that way? Expectations?

I've spent more hours than I'd like to admit thinking about this. I definately don't have the answer, but I'll try. At one point I was afraid that maybe it did boil down to a bruised ego. I don't think this is the case though. I get gratification out of my work contributing to a positive outcome for sure. Therefore, I don't get gratification out of a patient standing up and telling me I'm the greatest, and that I've cur