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Old 13-04-2012, 12:25 PM   #1
keithp
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Default Pain: "Choking" or " Panicking"?

I thought I would share with you the a couple of postings from a blog I am familiar with , with some questions for discussion (if you don't mind) in the post that will follow.

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Quote:
Under conditions of stress, however, the explicit system sometimes takes over. That’s what it means to choke. Choking is about thinking too much. Choking is about a loss of instinct…[a return] to the mechanical self-conscious applications of lessons [from the past].
I was fascinated as I watched a local sports star, who had an 87% free-throw shooting percentage, miss two consecutive free throws at the end of a close basketball game. In the end, his team won, but his exasperated expression said something to the contrary; it did not look that much different from the dejected look of a patient with “chronic pain”.

I wondered: what is it that made him choke? Could it somehow be related to my patients?

After visiting my favorite search engine, I came across this article, by Malcolm Gladwell. It discusses some of the most famous “choke-artists” in recent sports history including Jana Novotna at Wimbledon, Chuck Knoblauch’s inability to throw the ball to second base, and Greg Normans collapse at the Masters. In each instance, according to Mr. Gladwell, the athlete says to themselves, “Look, I’m going to be careful here. I’m not going to mess things up.’

Quote:
Then, after having decided to take that strategy, they calm down and go through [a] task. But that’s not the way to succeed…The more you do that, the more you will get away from the intuitions that help you, the quick processing…The usual prescription for failure–to work harder and take [a task] more seriously–would only make their problems worse.
Reading the passage above, reminded me of the words of Barrett Dorko, PT who suggests that,“Without any trust in the ideomotor activity necessary for correction [away from mechanical deformation producing nocioception], anybody would withhold its expression.”

If the athlete has practiced for hours and hours and has learned, implicitly, how to perform, why over-analyze? Simply put, they lose confidence (or faith) in their implicit ability perform.

But what of the patient in pain? If the patient in pain were to possess (implicitly) within themselves the means by which to reduce mechanical deformation, why suppress it?

Mr. Dorko hypothesizes that our culture has idealized a posture that is largely static in nature due to its intellectual discomfort with bodily expression that is unique and non-consciously motivated. As a result, the culture praises us for ideal stillness and “good posture”. In the end, the culture (and its expectations) drive the individuals movement (or lack thereof) rather than the individuals intuitive, non-volitional, deformation reducing ideomotion. (1).

Mr. Gladwell might say the patient is choking…
. . . .

Mr. Gladwell suggests that the only way to prevent an athlete from choking is to change the environment. In the instance of Jana Novotna:

Quote:
The only thing that could have saved her is if–at that critical moment in the third set–the television cameras had been turned off, the Duke and Duchess had gone home, and the spectators had been told to wait outside. In sports, of course, you can’t do that…Choking requires us to concern ourselves less with the performer and more with the situation in which the performance occurs.
Choking, like pain, is contextual (read: Neuromatrix). Unfortunately for the athlete, their environment is non-malleable; the crowd will not go home and the cameras will not turn off. Likewise, the patient in pain does not get to choose the culture they are a part of.
Fortunately for the patient in pain, however, they have greater control over the context of their pain experience. The athlete has to play their game or match at a predetermined time, at a predetermined location, against a predetermined opponent. Their choices are limited. The patient, on the other hand, can choose what they do, when they do it, and who they trust to do it with. This is where the skill of the clinician is important. After all, “If the motion necessary for relief must come from the patient, it is only likely to arise within an environment full of acceptance and faith in their inherent abilities.” (2)


How do you set up your therapeutic environment to assure that the negative influence of the culture is suppressed?


How do you help your patients learn to stop choking?


REFERENCES
(1) The Characteristics of Correction
(2) The Analgesia of Movement: Ideomotor Activity and Manual Care
Respectfully,
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Last edited by keithp; 13-04-2012 at 12:31 PM.
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Old 13-04-2012, 12:28 PM   #2
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In writing this blog posting, the correlation/similarities between pain and "choking" became apparent to me quickly. My thoughts above seem both clear and logical (certainly, however, if someone disagrees I would love to discuss it here).

In reading Gladwell's article, however, how the patient may "panic" in relation to pain (and seeking its release) was not as easy, although I cannot help but think it is equally important.

I have paraphrased, for your convenience, Mr. Gladwell's remarks on panic:

Quote:
"Panic" is characterized as a purely physiological response. The individual stops thinking. Stress wipes out short-term memory. Additionally, panic also causes perceptual narrowing. Essentially, panic is the opposite of choking: thinking too little, a reversion to instinct.
In my reading, I found a similarity between choking and the patient's inability to reduce their own pain implicitly. Theoretically, they (those her are choking) may need to "turn off" that which is explicit (in terms of motor planning/movement) to resolve mechanical deformation. My thoughts, however, is that there may be components of "panic" (using the characteristics of panic as mentioned above) in ideomotion. How does this fit (it is obvious to me that my patients would not be panicking if I were to elicit ideomotion)?

I suppose I am bringing this here in an effort to try to continue to work out this story, something that I think patients can find very relate-able. Conversationally, the culture's influence on their posture may not be as accessible to them as thinking of the pressure of playing at Wimbledon, the World Series or the Masters. I think the idea of "choking" on pain may be beneficial for some.

But... What about the patient who is panicking? What do they look like compared to the patient who is choking? How are their actions different? Would they still benefit from ideomotion? If they have reverted to instinct, why would they not have found ideomotion, themselves? My posting above makes it seem as if ideomotion is the opposite of choking, but if panic is the opposite of choking, does ideomotion lie somewhere in between?

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Old 13-04-2012, 02:35 PM   #3
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Keith,

Wonderful post. I will spend more time on it later today, but, in the meantime, are you familiar with Choke?
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Old 13-04-2012, 02:58 PM   #4
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Keith a few quick thoughts about choking and panicking come to mind.

I wonder if the panic tends to happen more after acute injury. Patient suffers some injury to a body part and panic sets in that stop thinking that injuries heal we just need to give them time and an appropriate environment to do what they naturally do. Their thoughts instead go to everything bad that might go wrong and they get stuck in defense and do not move toward resolution in the pain stages.

Whereas, choking tends to happen the longer the pain persists.

Just some early thoughts before the first patient of the day, so I will have to let it bounce around and see if anything else comes up as the day goes on.
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Old 13-04-2012, 06:49 PM   #5
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I can't let this lie... Norman's collapse at the Master's was bad, but it couldn't hold a candle to van de Velde at the '99 British Open:



You can see the befuddled agony on his face when he chips into the creek.
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Old 13-04-2012, 11:33 PM   #6
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Quote:
Originally Posted by zimney3pt View Post
I wonder if the panic tends to happen more after acute injury.
I can see this...I hadn't considered thinking of the chronic pain patient vs a patient who has only recently begun to experience pain.

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Originally Posted by zimney3pt View Post
Patient suffers some injury to a body part and panic sets in that stop thinking that injuries heal we just need to give them time and an appropriate environment to do what they naturally do. Their thoughts instead go to everything bad that might go wrong and they get stuck in defense and do not move toward resolution in the pain stages.
This is where I began to run into the problem with my reasoning. The Gladwell article would seem to point us toward thinking that the actions that result from a panic state are exclusively instinctive.

I tried to be content with using choking (alone) as a metaphor, but I felt unsatisfied not finding a way to wrap my mind around the idea that both panic and ideomotion are potentially instinctive...one destructive, the other not.

Thanks for the replies...

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Old 13-04-2012, 11:52 PM   #7
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Keith,

I still see it as instinctive. Think from a survival standpoint hunting in the woods. I am walking and hear a rustle in the brush. My instinct is going to be one of two options: run or stick around. Option A - stick around because most likely a nice deer that I can kill and make dinner with, Option B - it could be a large lion ready to attack me so I should run even though not to many lions living in Iowa. It is more likely that option A is what it is, but option B can be very powerful and overcome someone. Heck if I'm wrong and it is option A and I run away, I might be a little hungry but live to see another day. But if I'm wrong and stick around and it turns out to be option B, lights out game over. I think instinctively we still have options, some being better then others to act upon. The culture and context around the situation will help shape our instinctual decisions.
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Old 14-04-2012, 12:07 AM   #8
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Thank you, Kory.

Perhaps I am conflating instinctive with automatic...

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Old 14-04-2012, 12:33 AM   #9
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Maybe ideomotion is the spinal cord, feeling and acting a bit panicked..
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Old 14-04-2012, 02:32 AM   #10
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Quote:
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Maybe ideomotion is the spinal cord, feeling and acting a bit panicked..
As in reflexive?

I thought that one of the theories on idemotion and pain tied in with studies that show motor cortex activity (unobserved outwardly) that accompanies a painful experience...the potential for culturally inhibited movement that would otherwise satisfy the brain's thirst/hunger for movement that Wall wrote of.

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Old 14-04-2012, 02:51 AM   #11
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Yeah, I think you're right. I've always been confused about what ideomotion is or isn't or at what level.
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Old 14-04-2012, 03:02 AM   #12
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Quote:
Originally Posted by Barrett Dorko View Post
...in the meantime, are you familiar with Choke?
No, I was not. I am beginning to know what Byron speaks of with an all-too-long list of books to one day open. Meanwhile, I continue to consume Butlers text for the second time.

Thank you.

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Old 14-04-2012, 05:31 AM   #13
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Don't forget Moseley and Butler's new text on GMI coming out...always more reading to do...
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Old 14-04-2012, 02:05 PM   #14
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Quote:
Originally Posted by zimney3pt View Post
I still see it as instinctive. Think from a survival standpoint hunting in the woods. I am walking and hear a rustle in the brush. My instinct is going to be one of two options: run or stick around. Option A - stick around because most likely a nice deer that I can kill and make dinner with, Option B - it could be a large lion ready to attack me so I should run even though not to many lions living in Iowa. It is more likely that option A is what it is, but option B can be very powerful and overcome someone. Heck if I'm wrong and it is option A and I run away, I might be a little hungry but live to see another day. But if I'm wrong and stick around and it turns out to be option B, lights out game over. I think instinctively we still have options, some being better then others to act upon. The culture and context around the situation will help shape our instinctual decisions.
Thank you again for this perspective, Kory. For the sake of brevity...it is not important to view panicking through the spectacles of acuity, but rather an internal drive toward protection (Option B) rather than toward resolution (Option A). This makes sense to me; I might even say it sounds simple.

Of course, the night after starting this thread, I came across this from Barrett in my evening reading:

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If my handling is non-threatening and my manner implies no judgment or intention their brain now has an opportunity to drive their muscles in a unique fashion. If it’s an instinctive response beyond protection it will be ideomotion...
Thanks for the conversation...I think the story is crystallizing in my mind.

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