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A simple case

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  • #16
    Not that it's really relevant, but out of curiosity, where on the ocean did the seagull intially land?
    " I speak Spanish to God, French to women, English to men, and Japanese to my horse."------Buckaroo Banzai


    • #17

      Always the enigmatic question. I think the answer would be: On the surface.

      Glad to see you here.

      Yes, I tap toward external rotation. It's a quiet conversation, not a command.
      Barrett L. Dorko


      • #18
        How long has this individual been having this adverse neural tension?

        Did you see or the patient experience any change in knee extension as well after the 20 minutes?
        Kory Zimney, PT, DPT

        "Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

        "All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei


        • #19
          A couple of years as far as I can tell. Enough to prevent his painless walking anyway.
          Barrett L. Dorko


          • #20
            I am really enjoying this thread. Barrett, I have no idea how you help someone towards ER and abduction.

            I am interested in finding out.

            Thanks for this.


            • #21
              I agree with Proud.

              This is a fascinating thread. Especially having the opportunity to attempt to figure it out. Way out of my leagues but really enjoyable. Is this patient an older gentleman? I just assume so from the shoes.
              Byron Selorme -SomaSimpleton and Science Based Yoga Educator
              Shavasana Yoga Center

              "The first principle is that you must not fool yourself - and you are the easiest person to fool" Richard Feynman


              • #22
                It's nice to see how popular this has become.

                Several thoughts:

                I refer to this as a simple case because the management itself is simple - not the patient. Being human, he's got a lot going on as is common in the settings I frequent. I choose to focus.

                Not being a doctor, nurse, OT, speech therapist or social worker, I'm not obligated to "fix" all kinds of things beyond the scope of my practice and my interest tends to flag anyway. All day long I hear other PTs asking questions about issues that are none of their business. I guess they think this means they are "holistic." If they actually knew anything about the neurobiology of pain, well, that would be nice. They don't. They're just nosey.

                This, as it turned out, was an educable patient (to me, a much more important factor than age). Not everyone is. It makes a huge difference.

                I didn't take this man's leg into the position last seen - I followed him there. To me, the pain is neither a defect or defense - it simply motivates him to change. The change itself is brought about by unconsciously generated processes that are easily palpated and promoted. The muscular activity present is the beginning of movement along the corrective path. The muscular activity (isometric in the main) is a defense and thus it should be amplified. (see this)

                Combined with education about the characteristics of correction, metaphors the patient understands and the proper context, this can result in an enduring effect, as any learning might.

                Think of this: instinctive movement toward a reduction in neural tension is inherent to life. That doesn't mean it is always obvious, just that it's always present.

                Use it.
                Barrett L. Dorko


                • #23
                  As you can see below, better still, and this after 1/2 hour of treatment.

                  What you expect this new posture to provide?
                  Attached Files
                  Barrett L. Dorko


                  • #24
                    See here.
                    Kory Zimney, PT, DPT


                    "Study principles not methods, a mind that can grasp principles will create its own methods." - Gill

                    "All truths are easy to understand once they are discovered; the point is to discover them." - Galileo Galilei


                    • #25
                      My question is, now that he has external rotation is the pain in his right leg gone?


                      • #26
                        This is a really interesting thinking process to me.

                        So the problem is on the R hip???

                        " you can see in the picture below, taken ten minutes later, treatment has already resulted in an alteration of position that couldn't have come from any change there."

                        Barrett, what did you do in this 10 minutes......
                        Education...Metaphors....relaxing chat.... and putting your hand on certain area all together?? What made you to chose that area to start your simple contact??

                        as the Rx was done in lying, how you could transfer the effect of Rx into standing and walking? Any particular somatic exercises you would use to before this man got up?

                        Thank you,



                        • #27
                          That's so funny b/c only a year ago if you'd presented that photo with question, I would have said something about his L hip being tight, maybe even specified the piriformis or somesuch.

                          Now, looking at the initial photo, I can see the R seems restricted (or protecting) at the hip or thigh somehow. I can't tell you anything more than that.

                          Your photo has shown me how far I've come and how much more there is to learn all at once.

                          I would expect the new sensation to provide a better sense of movement for the patient as he walks.
                          "The danger is not that the soul should doubt whether there is any bread, but that, by a lie, it should persuade itself that it is not hungry" (Simone Weil)


                          • #28
                            I really like Kory's answer!
                            Weni, I can not speak for Barrett, but I would suggest that this
                            transfer the effect of Rx into standing and walking?
                            is something "we" do not do. When the patient goes through the process of experiencing the changes, often if not most always, the changes they perceive during the process translate to their other "postures" .
                            I am not saying they are done treatment.
                            They have already taken a big step towards their resolution.

                            Looking forward to Barrett's answer.
                            We don't see things as they are, we see things as WE are - Anais Nin

                            I suppose it's easier to believe something than it is to understand it.
                            Cmdr. Chris Hadfield on rise of poor / pseudo science

                            Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                            We don't need a body to feel a body. Ronald Melzack


                            • #29
                              At the end of four sessions in four days this gentleman could bear weight painlessly and take five steps with contact guarding. He told me that he no longer needed the nurse to help him from a supine position.

                              He was taught to simply draw up the right knee, his foot still in contact with the surface, and repeatedly externally rotate the hip while supine. He understood that he was not trying to stretch or strengthen anything.

                              I landed many places with my hands, didn't remove any clothing and always discovered more ideomotion waiting for a little help. This included the torso, head and neck. I wasn't treating his hip, I was treating his nervous system. He felt warmer, softer and was often surprised by these sensations as well as the movement evident to both of us.

                              He appreciated my humor and Nat King Cole from the computer.
                              Last edited by Barrett Dorko; 15-10-2011, 03:43 PM.
                              Barrett L. Dorko


                              • #30
                                I've got a patient right now with a very similar presentation, but she's only 42 years old, chases a 20-month-old around after she gets home from work, and has been told that she has a "bad disc". She frequently refers to her pain as synonymous with the disc: I lightly palpate over the lumbosacral junction and she replies, "That's my disc."

                                I could be under-estimating her, but for my patient, some level of "operative stance" is expected, and I'm afraid I'd lose the opportunity to help her if I didn't at least pretend to oblige. So I do. I have her do neural glides and activate her transversus abdominus (did I mention that she's had some plastic surgery her previously nubile female shape?).

                                Most patients live, to some extent, in a fantasy world, and I have to enter the fantasy in order to bring them back out through the "looking glass" to a place that is more consistent with the reality of being an aging human primate. This is the hardest part of the job. It's commonly and almost flippantly referred to as "patient education". Barrett describes using metaphors, humor, music and education about what correction might feel like. I try to do this without causing more confusion or worse suspicion from the patient, and, perhaps more precariously, alienation from my referral sources.

                                These acts of therapy, unfortunately, prove all too often fatal to the therapist. But, that has to be weighed against knowing what will happen to the patient if they continue down the biomedical path towards lumbar fusion where patients like this almost invariably end up.

                                It's just a shame that we have to continuously make these fateful decisions between our ethical duty to patients and our need to make a living.

                                Thank you very much for this thread, Barrett.
                                John Ware, PT
                                Fellow of the American Academy of Orthopedic Manual Physical Therapists
                                "Nothing can bring a man peace but the triumph of principles." -R.W. Emerson
                                “If names be not correct, language is not in accordance with the truth of things. If language be not in accordance with the truth of things, affairs cannot
                                be carried on to success.” -The Analects of Confucius, Book 13, Verse 3