Into the Future

[Barrett Dorko]

It’s been a quiet week in Cuyahoga Falls…

Too quiet.

Before I start teaching again in April and even beyond, I’d like to start seeing patients again. I haven’t done this since closing my own practice a year ago and though I have decades of thinking and handling within me I find myself a little intimidated at the prospect.

I checked out some out-patient facilities in the area and nearly latched on several times but one thing or another hasn’t worked out. This isn’t entirely someone else’s fault, and I can appreciate that I’m a therapist with a history of individualized care, thus making it hard for many clinics to fit me in.

So, yesterday I decided to return to work in a skilled nursing facility somewhere. I no longer care where. I will dive into the paperwork and politics wherever I go and count myself lucky to have a place to drive to each day.

I know that this blog normally makes a point of some sort and that it is generated by something I’d recently seen, but today I want to begin this and eventually write about what I’m about to see. It is about the future and how an old guy like me might adapt.

Please add whatever you like here; advice, even warning. I’m ready to listen.

[Diane]

Get lots of sleep.

[Luke Rickards]

Hi Barrett,

I usually make a point of not trying to offer advice to those with far more experience of life than myself.

I couldn't help but notice that after reading your post that the piece of advice that you often give to others was surfacing in my mind. I hope the future doesn't find you with that thought in your mind too often.

As usual, I look forward to reading what you do discover.

[nari]

You may find that, after a year of absence, you see patients and carers in a different light.
That can be very useful or not, but I suspect the former.

Nari

[Barrett Dorko]

Luke,

I presume you're referring to the "dead man" appellation I've used a few times. I try not to use it too often because I feel this may diminish its effect.

It may fit here though. We'll soon see.

[BB]

Good luck, Barrett. I'm anxious to here of your experiences.

[gerry]

As Luke and Cory mention, I look forward to reading of your experiences. This experience will benefit the patients you see, your readers, and probably the administration of whatever facility you end up helping. Hopefuly it won't be too unpleasant for you...

[christophb]

I'm looking forward to the writing that comes out of this as well. Do you think you have changed in any way since your last tour of duty in a SNF that might make it easier for you?

[Barrett Dorko]

It appears I'll begin next week, and feel ready. I'm older, wiser, I have less hair but more experience speaking to other therapists and that should help.

I still have difficulty seeing ahead clearly, but for the next three months this will consume me and I intend to offer what I can.

I just read the above and Man, I've been reading too many posts on the MFR list.

[Barrett Dorko]

Jan is…professional, which is a metaphor for cold.

Michael Scott speaking about his then boss, now his girlfriend.
Reference: The Office ( http://www.nbc.com/The_Office/)

It starts tomorrow. I’m going to drive forty miles early in the morning to a place I’ve never seen before, meet somebody for the first time and find my way through a day full of responsibility I’ve yet to discover. The next day I do the same thing in another building in the opposite direction. I’ll alternate after that.

There’s a scene in Dances With Wolves ( http://en.wikipedia.org/wiki/Dances_with_Wolves) that’s been going through my head the past couple of days. Kevin Costner finds the local native Americans in his camp and despite the fact that they speak different tongues and share a great wariness at the other’s presence Costner disarms his guests with generosity and good will. He’s even a little silly.

Now, I can’t really see myself being all this friendly and I sense that I’ve got to hold some of my natural humor in check. But I don’t want to come across like Jan either.

I want to be like Jim ( http://en.wikipedia.org/wiki/Jim_Halpert).

At the very least, I’ll spend less time watching TV.

[bobmfrptx]

Jan is…professional, which is a metaphor for cold.

Now, I can’t really see myself being all this friendly and I sense that I’ve got to hold some of my natural humor in check. But I don’t want to come across like Jan either.

I want to be like Jim (http://en.wikipedia.org/wiki/Jim_Halpert).

At the very least, I’ll spend less time watching TV.


Barrett I am assuming you are talking of the relationships between the co-workers and not the clients. Being like Jim ( from your link) .... "It is often implied through the context of Jim's comments and through the comments of others that he is not only overqualified for and uninterested in his job, but only stays because of his hope to be with Pam....... would be totally unfair to the clients. They are expecting the best you have to offer and I feel you have plenty.
Some of my fondest memories are about the people who desparately need contact living in SNF.
I applaud your courage.
Bob

[Barrett Dorko]

Late in the afternoon Annabelle holds my face in both hands and says, “bada bada, bada, bada, bada,” perseverating and smiling with delight. I think it’s my beard she likes.

Normally on a weekday of this sort I’d be in a rental car somewhere on a highway with the cruise control on, resting my legs and singing along with James Taylor. For now, that’s no more than a distant memory.

I wonder what they think of me; the other therapists I mean. To virtually all of them I’m just a large stranger wearing a tie. They presume I’m licensed and somewhat familiar with the work. I remain quiet about my background unless specifically asked a question and keep my answers brief. To most I’m just “a contract guy,” which means I won’t be around too long and that I don’t have to accept the supervisory roles that weigh upon them. I’m expected to produce, and I do.

What do the patients think? It’s hard to say. I doubt many have been handled in the manner I’ve developed over the decades but no one objects. Several have been very grateful for the change they sense and in some quiet exchanges have asked to see me again, not that they don’t like the others. I’m just, well, different. They have no idea how different.

I’ve already grown used to the intricate nature of documentation in these facilities and can see that a real expertise in such a thing would make me quite valuable to the people who appreciate the power of my license and willingness to work efficiently. I’m developing that rapidly.

But I doubt that Annabelle cares about any of this. She just holds me in her hands, and I hold her in mine. She seems thrilled for the attention and time I’m giving her. For all I know it helps her in the ways we hope it will, but that’s a subject for another day.

[Barrett Dorko]

I’m two weeks into this work and cannot help but feel that I’ve entered a river of some sort. Each morning I drive some distance to the shore and then dive in. Late in the afternoon I drag myself out, wet and exhausted in a peculiar way. Slowly as I make the long drive back home I shake myself dry and most days I leave the psychological effects behind. Most days.

While I’m in it, the river’s stream is unexpectedly changing and my main job seems to be to keep my head above water. The first few days it was all I could do.

My head is full of allegorical images related to this river theme and my plan is to write about them as the days pass. I’ve also got an allusion to Siddartha (http://en.wikipedia.org/wiki/Siddhartha_(novel)) floating around in my head that I’ll have to investigate this weekend. On the weekends I stay dry.

More soon.

[bobmfrptx]

Barrett,
I hope you are continuing to touch the clients as directed by your treatment regimen and not those of the penny counters. The local SNF is a mill utilizing repetive programmed exercises and ambidrags in order to keep the dollars rolling. I doubt the effectiveness of alot of the wasted minutes spent imposing strutured movement on a rigid fearful body which has been allowed to forget their own ability to be.
Keep treading water and add a few simple strokes of your own to the upstream swim.

[nari]

Barrett,

I'm waiting on the river stories.
I presume, so far, that the river hasn't actually got many crocs or piranha or snakes in it. Just murky with submerged logs?

Nari

[Barrett Dorko]

Bob,

Your post reminded me of a line from the movie Clueless I've always liked: "I could feel the chunks rising in my throat."

Thanks for that. It always makes me laugh.

The first thing I notice is that this river is mysterious. It has its own way of flowing and anybody who tries to understand that completely or change it significantly is asking for a lot of trouble. The water’s surface appears benign but carries with it a power never truly challenged by a mere therapist. The only way to survive is to realize that your actions must to a large degree conform to the river’s rules (more about them later).

First I encounter my co-workers. It’s clear that the river has had its way with them but for the most part they have found a way of staying afloat. I have yet to learn how this might be done. They speak to each other of their frustration and, occasionally, their hope that things might change if only the river would allow it. These conversations punctuate a day full of work and worry and an underlying sense of dread that goes unspoken of.

The first few days I found myself flailing about and thought sure I’d drown beneath a wave of paperwork and procedures I could only pretend to understand and follow faithfully. Since then I've grown better at appearing to understand and I realize that in order to be “good” at this job I’m going to have to work hard at doing things I really don’t like, don’t do well and go against the grain of what I think therapy should be.

Somehow I’ll begin to float with less effort, but I should mention that the view downriver is continually obscured, and no one knows what will show up the next time they lower themselves into it.

[bobmfrptx]

Barrett;
Glad you find me amusing. Also glad that it appears you do not actually agree with the flow of things at your place of employment. Keep up the subterfuge in order to remain productive, but please don't forget the power of touch and the effects which you described so well in the post re: Annabelle.

[Nick]

Bob,

What makes you think he'd forget? Though I'm sure he appreciates your reminder of the power he wields. Have you read the Manual Magic thread?

[bobmfrptx]

Nick,
The power he wields? Hopefully, he will use it to the betterment of the elderly who get the short end of the healthcare stick in this country.
Hocus pocus dominocus....I've Read IT.
Here is to the great powerful Oz oops Barrett.
bob

[Barrett Dorko]

Boy, now you're comparing me to a sociopathic con man. Which is it?

I don't need your reminders or your posts reminiscent of the dreck found on the MFR list. I presume you get the message.

[Nick]

Okay Bob, I'll spell it out one last time. The power reference was a sarcastic response to your reminder of the power of touch. Unless, of course, you meant the power to reveal something within the patient themself.

[bobmfrptx]

Barrett,
I am not calling you a conman. Perhaps you will be the contents of the trojan horse.
Gidy up good buddy. I truly feel you will make a difference in your own way regardless of my reminders and best wishes.
Bob

[bobmfrptx]

Why are you guys so touchy? Pardon the pun. I am sincerely wishing Barrett the best and hope his experiences lead to a better treatment regimen for the residents of SNF. Why do you always get your hackles ruffled when someone tries to be nice.
Bob

[Barrett Dorko]

You call it nice, I FEEL (an MFR byword) patronized (http://dictionary.reference.com/browse/patronise).

Don't bother with the obvious comment.

[bobmfrptx]

Its your reality feel how you wish.
Too bad you are conditioned to be suspicious.
Peace Barrett
Bob

[Bas]

Bob, I am sorry to see that the condescending tone of your posts - well-meaning as they very likely are - completely passes by you.
I will be specific:

Bob: please don't forget the power of touch and the effects which you described so well in the post re: Annabelle.

Why do you even assume he would forget...My goodness.

Bob: I hope you are continuing to touch the clients as directed by your treatment regimen and not those of the penny counters.

This implies that there would be a possibility of Barrett doing the opposite....


Bob: The power he wields? Hopefully, he will use it to the betterment of the elderly who get the short end of the healthcare stick in this country.

Hopefully....This implies that there is a chance he would not use it to that end....

You can see the condescending tone here now....But of course, now you can say that I am prickly or conditioned. Notice how I have NOT called you an idiot....

[bobmfrptx]

Bas,
Encouragement does not mean I would assume Barrett would treat any other way than he sees best. I was offering encouraging words...you guys read between the lines too much. I can see your point and my posts were not intended that way. You may call me an idiot if you wish...but thanks for not.
Go in peace to love and serve the world.....
Bob

[John W]

Bob,
Your speech is so infused with quasi-religious undertones and even overt phrases ("go in peace to love and serve the world") , that I don't think you even recognize how looney you sound.

If you did, you would stop it post haste.

If you don't, stop it anyway. It's annoyingly sanctimonious.

[Nick]

Precisely John. And that should help Bob understand why we can be so touchy. Besides that, we hate the theories he supports and how they color our profession.

[Barrett Dorko]

Now entering my third week I’m not thrashing about as frequently. My demeanor hasn’t changed but I sense that it isn’t the illusion I initially created. In other words, I’m calm because I actually feel that way – mostly.

Sam Keen’s (http://en.wikipedia.org/wiki/Sam_Keen) wonderful admonition ”Stress means you’re living someone else’s life” goes through my head several times a day and I’m working to make this job part of mine. There are many compromises here.

When I get the chance to float along with less effort I can observe those around me and make some guesses about how they’ve reacted to such a situation. So far I gather that few have my sensibilities of therapy or have enjoyed the community of therapists I’ve discovered around the world. They swim along pretty much alone and can’t see an end to this.

I can, but I know that there are rapids ahead that none of us can see.

[Jon Newman]

I'm starting this post with an apology to those who are enduring my semi-public infatuation with Leroy Siever's blogging about his experiences. To my mind, his blog entries are entirely relevant to the practice of physical therapy and a rare, longitudinal glimpse of one patient's experience with pain and loss of function. Learning another life (http://www.npr.org/blogs/mycancer/2008/03/learning_another_life.html) is today's entry.

I'm posting it here to extend/generalize Barrett's last remarks. Our reaction to life experiences seem to recapitulate themselves. For better or worse.

[Barrett Dorko]

Great link Jon.

Though I've made a conscious decision to enter this river it's clear that most of those around me are truly surprised to find themselves here. This includes any number of fellow staff and virtually all the patients.

I remember the very day my mother entered and then my father. Both received PT, neither reached the goals written on the 700 form and I think of that every time I write one for a patient newly arrived.

I'm surprised at how easily I have adjusted to the long drives, the hours, the occasional bouts of confusion and the fact that I'm surrounded by other therapists. I've encountered a great deal of patience from them and I hadn't anticipated that.

At times I actually swim with my own rather eccentric strokes. So far, no one seems to mind.

[Barrett Dorko]

Back during the dawn of The Disco Era I read Richard Selzer’s Mortal Lessons, Notes on the Art of Surgery (http://www.amazon.com/Mortal-Lessons-Notes-Art-Surgery/dp/B000S7VWY8/ref=sr_1_30?ie=UTF8&s=books&qid=1205181841&sr=1-30). I hadn’t read anything as literate from a physician since Awakenings (http://www.amazon.com/Awakenings-Oliver-Sacks/dp/0375704051/ref=pd_bbs_1?ie=UTF8&s=books&qid=1205182041&sr=1-1) and was excited by the possibility that I might one day work with people like this.

In the book he describes watching the Dali Lama’s personal physician, Yeshi Dhonden, demonstrate “pulse diagnosis” to a group of physicians at Yale medical center:

“In a moment he has found the spot, and for the next half hour he remains thus, suspended above the patient….holding the pulse of the woman beneath his fingers, cradling her hand in his.”

I used to read this whole passage to classes while still working in Atlanta in the 70s and would emphasize what Dhonden concluded but while reading this passage again in Hare Brain, Tortoise Mind (http://www.amazon.com/Hare-Brain-Tortoise-Mind-Intelligence/dp/0060955414/ref=pd_bbs_sr_1?ie=UTF8&s=books&qid=1205190734&sr=8-1) (I’m packing it to work these days for some reason) yesterday I noticed this elsewhere in the same paragraph:

“All at once I am envious – not of him, not of Yeshi Dhonden for his gift of beauty and holiness, but of her (the patient). I want to be held like that, touched so, received.”

These days I find myself taking a few moments to handle people in my way, using Simple Contact. I’ve heard a few tell me the same things I’ve heard of its effect for thirty years (the effect of the movement it reveals and the reflexive reaction to gentle skin deformation, really) but more than a few cannot speak, only feel. I do it anyway, and imagine that they are as grateful as Selzer would have been at being so carefully “received.”

[Barrett Dorko]

“I’d take the awe of understanding over the awe of ignorance any day.”

Douglas Adams (http://en.wikipedia.org/wiki/Douglas_Adams)

This quote jumped out at me a few days ago and has continued to rattle around in my head. I haven’t written much lately. I’m still finding my way into a new career as a clinician in the skilled nursing venues that will have me. I find that during the course of any single day I range from ignorance to understanding several times. Admittedly, some of the billing procedures and documentation is designed not to be understood, and if enough people come close they just change it. (I don’t know who “they” are – nobody does)

For years I’ve told my colleagues this: The sad situation we find ourselves in when it comes to treating painful problems, including our own, can change, but we’re going to have to understand something. I’m going to work today to teach you what that is.

I can do that, I think. But if I were ever asked to teach another what it is I’m doing these days I’d be lost. I’d say, “I’m in awe several times each day, but at least half the time I don’t know why.”

[smikolic]

This is an awesome way to put it Mr. Dorko!

"I’d say, 'I’m in awe several times each day, but at least half the time I don’t know why.'"

Maybe that is what we should all be taught... and to teach our collegues... "live to be in awe at least a few times a day!"

[christophb]

To be in awe and not know why would be "awe and ignorance". I don't think this was meant to be a good thing. Also, a) I don't think it's possible to teach "awe" and b) "awe" doesn't help patients, understanding does.

[Barrett Dorko]

Thanks Chris. I didn't want to break it to him and I appreciate the help.

[smikolic]

I guess I thought the "awe" was the understanding... not my own... for I have very little yet...

But my patients. They learn and they use it and I am in awe that this thing I used... whatever skill it was (usually after trying many) worked. I am in awe that they are better...

Sorry guys.. that's what I wanted to live for!

-Steph....

here's a litte story too:

I feel lost…. and found….

How can these two feelings overtake me in such truth of their existence that I cannot deny either one?

I have found, using by my reflective, creative, loving, touching and teaching side that I can be a very successful PT as far as pt outcomes are concerned (through no readily acknowledgeable “skill” I can see). The only way I know that it is good and I am on the right track is the vague feedback from my professors and mentors that “I get it.” But I don’t know just what exactly I am getting… or how to get more!

The other is the lost side, and very much as deeply felt. I am lost in a hospital clinical setting, with a CI who has literally boxed herself (her thought process, her treatment, and her every interaction) into the little boxes on the daily note forms in the patient charts.

I have tried to both think and ask outside the specified boxes, but no in no less quantifiable or skilled ways, and I have been thwarted at every turn. I am trying to convince my saddened/compressed mind that I am working under her license (and hoping that will bite my tongue for me) but my mind keeps screaming and my lips keep asking, “But what about this?” or “Could I do that?” to my and my CI’s excessive chagrin.

I will live in her boxes for my 5 weeks and be free again… but the constant reminder of my recent freedoms, acceptance for my creativity and successful implementations are leaving me hard pressed each day to cope….

Perhaps in this I will see what it is that I get?

[Barrett Dorko]

This is some kind of joke, right?

If not, PLEASE STOP.

Signed,
Mr. Dorko

[smikolic]

No unfortunately for me this is not a joke, Mr. Dorko. I am reading this website's posts, and trying to understand what it is to be a "thinking/open" PT in the narrow realm of the "real world."

Beyond this, I don't know how to explain to a "real" PT (as in the one I am following on this clinical) why I think it would be nice to try some functional testing on someone who has Alzeimers because they can't follow cues for traditional muscle testing as an alternate measure of strength, even though it doesn't fit in her little boxes. I am confused when PT's have so many options for treatment and testing, but they get stuck in a routine of prescribing the same exercises on every patient, regardless of their diagnosis (Ortho post-surgical, alcoholism, COPD, alzeimers, etc.). These patients are all unique to me, and they have different needs and not all of them particularily like doing SLR's, quad sets, TKE's etc. 2x/day with a PT who then proceeds to bill it as "skilled" care. I was under the impression that skilled care is that of a program catered to a client, not some cookie cutter approach. I just don't see the cookie cutters.....

How does one find others who think similarily? How does one teach others to try to think outside the box, even if it isn't initially comfortable?

I heard you were a teacher of some unique methods of helping to relieve pain...and I would be interested in learning them, and I plan to attend your classes in the future. I heard that you are a unique thinker as well, as is evident by your writings.

I am here because I don't want to be boxed in, especially as I am just beginning. The joke's on me, I guess, if I thought that coming out of school I would be exposed to open-minded professionals in an open-ended field with a whole lot of patients needing exactly that type of "understanding" and a willingness in their practicioners to try other techniques such as Simple Contact or learning through movement. I have tried to teach my patients how to use pain relieving movements, and I have put my hands on people and waited for them to move (and to my amazement they did, and in ways that they have responded by getting all warm and relaxed and pain free), but I don't really know what they did or how they knew to do it (or how their bodies knew)! I am amazed that these techniques have been successful especially when other "real" PT's have tried all sorts of exercises/teaching/modalities but have not helped them and they have lived in, and even accepted on some level, their pain.

I am looking for understanding in how these techniques are theorized to work, and why they are so successful in patients who have not previously had success with meds, other practicioners, their own attempts at management, etc....especially because they truly have tried everything they could before coming to me. I don't know what to tell them, or my colleagues, as to how this stuff works or why it works where other techniques have not. I don't know how to tell my collegues why they should try some different approaches, especially if I can't find evidence on it anywhere. I am looking to learn about the techniques, and the practicioners who use them, in the hopes that I can learn about myself, and about where I belong in the realm of PT (besides helping patients in pain).

[Jon Newman]

Hello Steph,

I've got a few thoughts here.

Unfortunately it sounds like you don't have good rapport with your CI. I don't have any great suggestions on how to change that. Try something different than you're doing now. Pretty profound, I know.

As far as improving your understanding, you may consider starting a new thread with some research you've read and would like to analyze/share.

You may also like some of the stuff in the Doctor Talk to Me (http://www.somasimple.com/forums/showthread.php?t=3663) thread. It might help define the box that's missing on the forms you're filling out.

[bobmfrptx]

Smikolic
Keep looking in the face of the negative feedback. Each individual is unique in their dysfunction and require some insight in to their own personal mechanism of function in order to sucessfully "treat" them. This is usually found in the initial evaluation question answer period. Continue handling your clients in your manner and mix in the things you have learned when appropriate. Dare to swim upstream rather than struggle in the current of mediocrity. There are some things to be learned here, but sensitivity, love and feelings are frowned upon in the scientific minds due to there unquantifiable characteristics. Use them anyway and good luck in your journey. Read Barnes, Borysenko, Barrett, whomever, AND draw your own conclusions.
Bob

[Jon Newman]

There are some things to be learned here, but sensitivity, love and feelings are frowned upon in the scientific minds due to there unquantifiable characteristics. Use them anyway and good luck in your journey. Read Barnes, Borysenko, Barrett, whomever, AND draw your own conclusions.Bob, this is about the biggest misunderstanding I've seen from you yet.

Steph, I do agree with Bob that you should draw your own conclusion but you may also want to discuss those conclusions with others to help determine whether the conclusions you've drawn on your own are in error.

[bobmfrptx]

Sorry Jon,
Thats my impression. Barrett doesn't want patients to love him or bring him cookies or gifts. Ugh I believe was his reply... The therapeutic presence is discussed often...is that the love sensitivity and compassion label?
BOB

[Jon Newman]

Ok, I stand corrected. It was the second biggest misunderstanding I've seen from you.

[Diane]

Bob, a line should be drawn between the role one inhabits and one's personal boundaries. Someone bringing cookies or declaring love for their therapist, to their therapist, violates personal boundaries. It can be discouraged in numerous ways, mostly covert, that are not offensive.

Therapists who need such expressions of adoration, who need some external clue to help prop up their own habitation of the therapeutic role, violate a boundary inside themselves, one that should be kept clear and held firm. Therapists like this probably encourage such behavior in numerous ways, both covert and noncovert.

Neither have anything whatever to do with compassion or love or sensitivity. Both have to do with boundary issues.

[bobmfrptx]

There is no need for this Diane and I do discourage gifts of any sort. However, it appears to dampen the spirit of the giver. So now I accept gifts with gratitude and humility and share them with whomever is in the office.
Lets keep the white coat in medicine.
god forbid we humanize it.

[smikolic]

Thank you all for your feedback. I too have some difficulty accepting gifts... though many patients (when I was a nursing assistant, and now as a student PT) have tried, and if it is nominal I will graciously accept, but always following with something about how I am just happy I could help, I am not doing if for the gratitude, or how it really was the patient who healed themselves, I just am here to help their process along.

I am trying to "swim upstream" I guess I was not expecting there to be so many PT's out here who are not on the same boat. I am frustrated with the inability to connect with anyone so far in my clinical rotatations who will even discuss techniques or their use or theories behind their effects. I can't even talk to my own CI about different types of testing, I dare not bring this up!

I was sent here by my mentor from school. I didnt' realize I would really need a community when I graduated. I just thought it'd be fun to chat. I am realizing it may be the support system I need to swim when I get tired of this stream (as I may in the future by the looks of it). You all are the islands along the way I may find port for a minute before I try again. I am glad for that.

Oh, don't be gentle with me...which by the looks you all will not bother with that (I like to be prodded...it advances my learning, and I tend to get stuck a lot yet).

I have some theories on Simple Contact and stuff to bounce off you all tonight when I get home. I am ready to spit it all out and see what you all can help me to advance my understanding, because though I have read the threads here and through my own limited reading (they don't teach a lot about anything in school... no time), I am interested in getting a better grasp on what I do understand, and a better idea of what I don't and where then to get more info.

But more later... I have a lot of questions and I possibly a lot of misunderstandings, but I'm not sure.. hoping you all can help.

Again, thanks..
Steph

[Diane]

Hi Steph,
I have some theories on Simple Contact and stuff to bounce off you all tonight when I get home. I am ready to spit it all out and see what you all can help me to advance my understanding
That's what this board is for. :)
Are your theories you'd like to bounce based on neuroscience?
don't be gentle with me
Sounds like you already have thick virtual skin. It does come in handy sometimes, especially those moments when a whole cognitive world seems like it goes upside down for a time.

[nari]

Steph,

Hope your efforts to understand the art of PT intervention (and any other intervention) are rewarded. This site will certainly assist, and reading some of Barrett's Cuyahoga letters is a good start.

Re the love/sensitivity issue: one can be sensitive, kind and empathetic and receive gifts while working within the scientific realm. There is no mutual exclusion here. Barrett calls it 'caring'. It is a safer word than 'healing' which has dubious overtones. In fact, if we are not sensitive to another person's CNS, we won't be as effective in assisting their recovery.

I agree totally that a PT who 'prescribes' sets of exercises for everyone regardless of complexity of their status, is not practising therapy at all. Yet they are everywhere, I'm afraid.

Most of us here have experienced swimming upstream to one degree or another, like trout. It is good to get to calmer water where swimming around is much easier. And we don't die off when that calmer water is reached. :)

Nari

[smikolic]

OK, Here goes....

I come from an extensive background in healthcare (14 years). I was a nursing assistant for over 6 years and have worked in various aspects of the healthcare system since I was 16. I have wanted to be a PT since I was young, because in this profession, and in the therapeutic arts alone I currently believe (but realize even beliefs can change), we are empowering our patients to heal themselves. Especially working in a hospital, I saw first hand how much therapists stood out from the rest of the medical community in how they approached and treated the patients, though part of it could simply have been I was really watching them more closely....who knows.

I was going along pretty much like any student in a PT program here in Wisconsin and suddenly I gained a rare glimpse into the realm of the surreal when I witnessed pt get unwound during a treatment I was watching. He started to move in really strange (at the time I thought them strange) ways and his pain went away. I was in awe because the therapist really didn't do anything. I have carried that with me since that day. I even tried it on my patients. For example, I put my hand on the top of a woman's head (who had cervical pain) while she was sitting in a chair and applied very gentle inferior pressure and told her we were going to move in ways that make her comfortable, and I waited... and she began to move and get all warm, and her pain went away. I have also worked on a few people with shoulder restrictions and pain who have been able to move after I handled them, trying different techniques such as PROM and gentle distraction with pertubations, and they suddenly were able to move again. Other PT's asked me what "magic" I have in my hands. I don't have any idea what it is I am really doing, despite my attempts to understand by looking over this website and by my own associations.

I have some "theories" though:

I think part of these techniques, or my "magic" (as other people have called it), is I listen to my patients, I don't talk much to them.. except when I do it is very friendly and accepting. I teach to them in ways that they learn, never scolding, and really not a lot of telling them anything beyond associations of pain and anatomy and connections of one body part to another and all to the brain. My teaching though, besides that inherent in touch, is a lot of asking back and re-directing them to their own bodies and feelings of the movements we go through. They seem to take more out that way, and I don't have to explain as much when they tune into their bodies... they seem to understand better when they "think inside" (is what I call it) rather than think what I do. I think I am offering them an accepting, non-judgmental place and a set of hands they can trust in which they can try to move again, which is the other part of my "magic," I think, that I handle them gently (not all of my patients yet, but the ones I am attempting to get to go into themselves.... that inner healing part that people seem to have). I get them to relax in my hands. I feel like with me they have permission to try to move. This is part of what I don't get about what I am really doing.... where does a person who couldn't move their arm actively (or even intially allow me to move it) suddenly begin to have painfree movement when I am done? What changed really? How can relaxation take pain away and continue to keep it away?

Oh, not to get too off track, but I wonder if the "fear response" thing that causes all the guarding in some people with chronic pain and on one of your threads was theorized as a barrier to be broken perhaps (like the man with back pain who ran after his children and gradually healed) is actually a part of what joint mobilization does.. Neurologically I wonder if the mobilization may be causing a quick stretch that serves to shock the muscles. When the patient finds relief from the mobilization, and we begin to get them to as I say to them "use the motion we just got," they begin to move again... perhaps not directly from the mobilization, but from their belief that the mobilization gave them some movement back... perhaps by these techniques they again have permission to move.

Back to relaxation and chronic pain relief... I think I understand how skin and brain are from the same origins... and are intricately connected throughout developement, and that by touching the skin you are actually touching/teaching the brain.... But I don't get how it all works. Am I teaching the brain to be painfree somehow? How does simply moving in a supported way get a person to be painfree and beyond that to move again?

I know my understanding is incomplete at best.... I want to understand the techniques at a level I understand strengthening a muscle. I am not satified with incomplete knowlege, as torturous as it may be to get a better grasp. I want to understand it in my brain the way a patient can understand my hands and my intentions in their bodies. I want to be able to verbalize what it is I am doing.

I have a psychology undergraduate, so I guess that I come partially from a neurological tract in my thinking but I also respect, admire and love the anatomical tract as well. I am definitely a people oriented care-giver (not so much practice oriented), but I am open to any and all explainations that could enlighten me and any guidance that could sustain me.

And, for all it's worth from this early on in my career and in my limited capacity to really have any perspective on what all of this may mean for my chosen path, I am thankful for you people! I really didn't know I'd be that odd in clinic, or that others would not be doing this stuff. I'm glad there are many who are quite "out of the box." Good thing for our patients!

Sincerely,
Steph M.

[Luke Rickards]

I'm glad there are many who are quite "out of the box."Hi there Steph,

From a certain perspective, it's accurate to say that many of the regulars here are practicing "out of the box". However, I'm sure we would all agree that to pull this off and not sound like a complete loony to colleagues requires an enormous amount of knowledge, a very critical mind and a great deal of precision in applying relevant concepts to clinical practice.

You have made an impressive list of knowledge gaps and assumptions above (which is not to say we can answer all of these questions either). It seems now would be the time to get to work. Perhaps you might start your reading with some of the references listed here (http://www.somasimple.com/forums/showpost.php?p=45097&postcount=1). Jon's suggestion (http://www.somasimple.com/forums/showpost.php?p=49635&postcount=41) is also an excellent way to start honing your critical thinking skills.

[smikolic]

I'm on it!

Thank you Luke.

[nari]

Steph,

A word about the man who ran after his children(I think it was in a post of mine).
Pain is a perception and probably an emotion, although the jury's a bit out still on that one. This guy was panicking; the brain/CNS will permit him to run because of the danger - either to him or the kids, whatever.

A severely injured man can do extraordinary things to escape his fate of being eaten by a bear or dropping off a cliff; a man with no actual injury (as with quite a lot of LBP folk) can do the same.

It's a survival measure; as soon as danger perceived by the brain has passed, the pain usually returns. This fellow was perpetually trying to protect himself from activity and he had chronic fear of more 'damage' if he moved wrongly. So lack of movement and fear maintains the perception of a threat, but not danger.
The experience showed him what he needed to do - move without fear- and he did very well.

Keep reading here, and ask if you get a bit lost in the concepts. As Luke pointed out, we will try to answer them helpfully!

Nari

[smikolic]

Steph,

A word about (I think it was in a post of mine).
Pain is a perception and probably an emotion, although the jury's a bit out still on that one. This guy was panicking; the brain/CNS will permit him to run because of the danger - either to him or the kids, whatever.

A severely injured man can do extraordinary things to escape his fate of being eaten by a bear or dropping off a cliff; a man with no actual injury (as with quite a lot of LBP folk) can do the same.

It's a survival measure; as soon as danger perceived by the brain has passed, the pain usually returns. This fellow was perpetually trying to protect himself from activity and he had chronic fear of more 'damage' if he moved wrongly. So lack of movement and fear maintains the perception of a threat, but not danger.
The experience showed him what he needed to do - move without fear- and he did very well.

Keep reading here, and ask if you get a bit lost in the concepts. As Luke pointed out, we will try to answer them helpfully!

Nari

So lack of movement and fear maintains the perception of a threat, but not danger.
The experience showed him what he needed to do - move without fear- and he did very well.


Nari,

So part of Simple Contact, is helping a person move without fear and then they simply continue to do exactly that? Is it the fear that causes the pain, or the pain that causes the fear? Or perhaps a bit of both, depending on the original pain source I wonder......but how does fear cause pain? Can it? I get how pain causes fear, and then a guarding of movement....

I think the other thing I am having trouble at this juncture understanding is how exactly simply moving can relieve pain... what does movement have to do with pain really? I will be checking out the articles Luke posted, maybe some answers are contained within. I already read the Doctor Talk To Me article... wow.

[EricM]

Hi Steph, welcome to SS.
You're asking the right questions. I think you'll find a lot of answers in Lukes' links. I'd also suggest spending some time with the essays on Barrett's site for some deeper perspective on the relationship between pain and movement.

[smikolic]

While in the shower (great place to think)... I came across a thought, at best a better track to the right answer about how fear can cause pain....

Perhaps it is not simply fear that causes pain, but the immobility or guarding or whatever response it is that the body takes on to the fear that is the causer of the pain? What do you think?

[Barrett Dorko]

It isn't obvious that Erickson did much of a job teaching you about the problems with searching for cause or anything about pain's four origins. I suspect this is common in our academic institutions. No wonder the massive confusion.

[christophb]

Careful, causation is awefully hard to determine acurately. Another good bit of reading might be found here: Five Questions (http://www.somasimple.com/forums/showthread.php?t=2404&highlight=five+questions&page=4)

[Jon Newman]

I'm glad there are many who are quite "out of the box." Good thing for our patients!

Hi Steph,

Consider checking out the essay in this post (http://www.somasimple.com/forums/showpost.php?p=43082&postcount=1)

[nari]

Steph, it is hard to go past Barrett's essays for many of your questions, and do look at the 5 Questions link, as Chris has suggested.

Briefly:
Simple Contact is a descriptive phrase; ideomotion or instinctive movement comes from the patient's nonconscious. The therapist does nothing except quietly wait for this movement to emerge.
It is actually quite important that the therapist does nothing, and that the movement is expressed by the patient nonconsciously. If the therapist suggests anything, the movement will not be instinctive and may not be useful.

If this sounds odd, keep reading. It does take time to absorb the science and the rationale/reasoning behind instinctive movement.

Nari

[smikolic]

From Mr. Dorko's post:
It isn't obvious that Erickson did much of a job teaching you

Mr. Dorko,

I'm sorry I ever mentioned Mr. Erickson's name for I would hate anything but a positive light to be shed on his name and his contributions to this profession.... He has taught far more to us (all of his students) than any other professor I have ever had (and have ever heard of). He has guided us to see the whole patient, beyond a diagnosis or impairment, and he is one of the reasons my passion is to treat the "whole patient" by looking beyond the impairments/diagnoses/functional limitations to the person who is experiencing a dysfunctional time in their lives, as we are able in our chosen role as a PT. He has taught us far beyond Ortho (the main class he teaches in our program). I'm quite sure he introduced us to the ambiguities of pain and it's many origins, and to our job in treating them (if the cause of the pain is there to be found by the tools I have, and if I am skilled enough in my assessments to find it).

It is not his lack of teaching I am sure, but my lack of learning/understanding. I believe most of the learning that happens in school/life (as does he by his teaching style) comes from active searching of knowledge by the learner (or seeker of learning) and an active reflective process on that learning, so that one may glue the information into their head and not simply spit out memorized concepts/lists. The teacher's job, I believe, is to show the students where to look to fill in the gaps after introductions to concepts are given, and he has led me here! I may have missed something, in my attempts to learn, about specific causes of pain beyond the biological causes I am familiar with, or I may simply be currently unable to link all of what I do have in my head together in a cohesive, speakable way that can be easily expressed with well rehearsed phrases to my collegues/patients and in a way that makes me comfortable that I have any knowledge at all. I am here to "fill the gaps" in my knowledge, not to seek teaching, or a better teacher. I am sorry to have led anyone, especially you, (because I am under the impression that he respects you), to believe that he did not teach us something by my seeking knowledge I do not have readily available to my concious thought process.

I am going to be looking up the studies that Luke has led me to... I will connect to the other links too that John and Chris have suggested. I expect this knowledge to be complicated and time consuming to take in (and I will take my time learning it as I study for the licensure exam as well... this will be a treat for me!) and I don't expect to understand everything I read completely right away, but that is my favorite part of PT...that I could always know more, or understand it better, or apply concepts to several situations I did not initially know I could. If PT were easy to learn/apply I couldn't love it for long!

Thank you all again for your feedback, and I am sorry I ever gave the impression I was not taught well, for I believe if it wasn't for great teachers like Mr. Erickson and all you generous people who are guiding me to where I need to go to learn, I would be a stagnant PT in a very short time, and I HATE to stink!

Sincerely,
Steph