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The Perfect Pain Patient?

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  • #16
    PAIN EDUCATION. I had my student work with her for about 45 min
    Hi Jason,

    What does "work with her" mean? I get the general educational things that were covered, I think, but tell us more about the ideomotion aspect of treatment.
    Last edited by Jon Newman; 02-01-2006, 04:36 AM.
    "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

    Comment


    • #17
      Nari-
      I used the deep neck flexor exercises because she had a history of occipital headache and she had chronic neck pain. This exercise progression has shown to be of benefit for these subgroups of patients. I think the proposed mechanism of increased use of deep cervicals and decreased use of superficial cervicals along with mobilization of posterior neck structures (where she was TTP) is a fairly good reason to select that exercise. It at least gets her to move the painful part and I always teach it in conjunction with diaphragmatic breathing, so I think it might help to reduce her sympathetic dominance as well.

      Jon-
      I did not get too far in my work with her, as you might imagine, the history alone was extensive, so I didn't get into specific pain relieving motions. I think generally she made mention that static postures and prolonged activities worsened her pain (go figure) but no specific movements that she could remember.
      On ideomotion: we discussed it briefly in terms of the automatic motions designed to relieve pain. I gave her the "hand on the stove" example of pain attempting to produce movement, and the example of children who shift to find comfort naturally. I discuss the diaphragmatic breathing and lowering autonomic state and to relax and allow the body to move whichever way it naturally wants to.

      I think at this point, I am reaching the end of my expertise in terms of encouraging and eliciting ideomotor movement.
      I have tried to do this manually, and I always end up sitting there feeling foolish, while the patient waits for me to do something. Even after a good intro into what it is we are trying to accomplish, I don't seem to have much luck getting those characteristics of correction that Barrett writes about and that I have asked the patient to look for.

      However, I expect to see her again, and to quote King Arthur (played brilliantly in 1974 by Graham Chapman): "So anything you could do to help, would be.......well.... helpful."

      J
      Jason Silvernail DPT, DSc, FAAOMPT
      Board-Certified in Orthopedic Physical Therapy
      Fellowship-Trained in Orthopedic Manual Therapy

      Certified Strength and Conditioning Specialist


      The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

      Comment


      • #18
        Jason, try the following:
        1. Stand behind her (if she's tall and you aren't, have her sit), and place your hands very gently on both sides of her head. Hint: have warm soft sure hands and do not press them into her bones, or wiggle them around. Just lay them on top of the skin. Tell her you are only going to touch her skin with them, not "do" anything with them.
        2. Ask her to let herself go inside for a moment, and "imagine" a way to "move in a way that will relieve pain," and then feel free to go ahead and let herself start to move that way, then let herself continue the movement.

        Do 1. and 2. simultaneously.
        Wait for three seconds. OK, wait as long as 5 seconds. Something will start to happen. The eyes will close and roll back, the head starts to bend slowly backwards into extension or off to one side or other. The movement will proceed from her own vertical axis. She will be in full control but will seem a bit hypnotized or something. She isn't, she's just moving from a nonconscious place although she will be completely aware of you and of herself. She might think you are moving her. You aren't - so tell her so. Tell her if she asks, that she is in full charge of this, that it's coming from inside her own motor areas of her brain. Try to stay in contact, on the lengthening side if you can. Only contact. Don't try to take over or help. She'll keep going as long as necessary, 5-10 minutes probably. New parts of the spine will add themselves to the movement. She may bend in all sorts of novel ways. Don't worry, let her go. To her it will feel effortless. Ask her if she feels warm anywhere. She will probably say yes, in general, or yes, in some body part. Let her continue until she stops on her own if possible, or, if you run out of time, you'll have to interrupt by saying something like, "..that's great.. we have to stop unfortunately because we're at the end of our time, but take a moment to complete this last little piece." Save a minute or two to check through the little list of 4 characteristics of correction, WESS. (Warming, effortlessness, softening, surprise.) and to reinforce that the patient produced this movement all by herself out of her own genious brain, and that she can do this whenever she wants, that she doesn't really need your hands to accomplish it although it's been a help to get her started.
        If you don't sense any movement after contact for 5 seconds, move your hands to the shoulders. Elbows. Outside of the hips. Lateral contact points over bone where skin has the best reception. Good luck.
        If you think you need to practice it first before trying it on an actual case pick your wife, or a child, or a co-worker, or a receptionist. Basically they need a body, a nervous system that is intact. They don't need to be in pain to notice they feel good doing this.
        Diane
        www.dermoneuromodulation.com
        SensibleSolutionsPhysiotherapy
        HumanAntiGravitySuit blog
        Neurotonics PT Teamblog
        Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
        Canadian Physiotherapy Association Pain Science Division Facebook page
        @PainPhysiosCan
        WCPT PhysiotherapyPainNetwork on Facebook
        @WCPTPTPN
        Neuroscience and Pain Science for Manual PTs Facebook page

        @dfjpt
        SomaSimple on Facebook
        @somasimple

        "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

        “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

        “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

        "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

        "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

        Comment


        • #19
          Jason,

          Diane has given a wonderful description above. Can I add, if you get nothing after 5-10 seconds with the hands on either side of the head, try one on the forehead and one on the occiput - very gentle. I find this contact the fastest way in. You really don't need to explain much to get movement. In fact, I leave the explanations until they have started to move or after the session. I think the surprise factor , which is greater when there has been no explanation, is a valuable part of this approach.

          Try Diane's suggestion: come behind a seated friend or receptionist (someone who won't feel uncomfortable with unannounced touch), place your hands very gently/comfortingly around their forehead and occiput, then wait. Be ready to follow them at the first incling of movement.

          Luke
          Last edited by Luke Rickards; 02-01-2006, 11:41 PM.
          Luke Rickards
          Osteopath

          Comment


          • #20
            Hi Jason

            I can see the rationale behind the use of deep neck flexor activation, and would be interested in how she reacted to the movements. I have found, sometimes, it aggravates a sensitive CNS, but not always.

            You mentioned she reported that static and prolonged activities increased pain; makes perfect sense when you think CNS and not muscles. The brain dislikes lack of movement and prolonged activity, depending on the activity, and will provoke a "OK, stop doing this..time's up for tolerance threshold" when sensitivity has contributed to a low adaptive potential. Jon can answer this one better, most likely.
            Can't add to Diane's description of eliciting corrective movement..except to emphasise that the touch is light, non-invasive and, I think, accompanied by silence on your part after you have given the 'permission to move'. Have you tried it on youself, without or with discomfort/pain present?


            Nari

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            • #21
              Jason,

              Your description of that particular treatment session sounds very familiar to me as it describes my early practice. Diane and Luke's ideas are great.
              "I did a small amount of web-based research, and what I found is disturbing"--Bob Morris

              Comment


              • #22
                Wow...this is an interesting discussion! I have to admit that my knowledge of Simple Contact is rather poor, but I am still learning new things each day...especially from reading y'all's (forgive me I'm a Texan) posts.

                Jason's patient in question seems very similiar to a patient I began treating on12/28/05 with a diagnosis of "left SI pain and bilateral knee OA". She told me she had a history of LBP and bilateral LE pain and occassional numbness. Per the patient, "I have that neuropathy in my legs and I take Oxycontin, etc...". For lack of a better explanation, she is a mess.

                Three days later, I see that Jason posts this topic and a light bulb went off inside my wee cranium. I thought to myself, "The next time you see this patient, look at how she presents in supine, check extremity temperature, breathing patterns, etc.". Well, I did just that today and finally was able to see most of what Barrett has been referring to in regards to sympathetic dominance. I know...I'm a slow learner, but at least things are suddenly fitting into place and making sense. While in supine, her left LE was internally rotated and slightly adducted with her foot towards the ceiling, left foot was slightly cool to touch compared to the right, and was breathing with her chest as opposed to her diaphragm. After this, I took her into a private room and UNLOADED on her left SI joint...wham! Just joking...LOL! I tried my best at performing this effortless technique of Simple Contact, of which I have no experience except from what I've gathered on this site and formerly R.E.

                I placed my hands on her left hip and knee, moved down to her knee and tibia, and finally her knee and lateral malleolus. I waited 3-5 seconds at each position until I began seeing her left LE externally rotate and slightly abduct. Prior to all of this, I made sure she understood what I was going to perform and provided her the best explanation I could of ideomotor movement and even used the same example Jason did of students sitting in class changing positions. She didn't report a dramatic decrease in pain, but did report some warmness and some decreased pain.

                I forgot to mention I preceded this treatment with some nerve gliding, i.e. SLR with DF/INV/EV and that gave her some relief as well. All in all, I felt really good that something gave her relief from her pain. I have a great deal to learn, but this was surely a start for me. "Left SI pain and bilateral knee OA" seems like the least of her problems. An "abnormal neurodynamic" seems more appropriate for her.

                Thanks for allowing me to ramble!
                Chris Adams, PT, MPT

                Comment


                • #23
                  Diane,

                  Do you normally treat with S.C. in the standing position or does it differ from patient to patient? Probably a silly question, but I thought I'd ask. How about the rest of you? Shouldn't the patient be in a position that is most comfortable for them during this type of approach?

                  Thanks!
                  Chris Adams, PT, MPT

                  Comment


                  • #24
                    Chris,

                    Every position has its advantages. I don't seek comfort, I seek freedom.
                    Barrett L. Dorko

                    Comment


                    • #25
                      Barrett,

                      I figured as much in reference to positions. 'Comfort' versus 'freedom'...I need to be careful with my word selection around you, however, I do agree...freedom makes more sense.
                      Chris Adams, PT, MPT

                      Comment


                      • #26
                        Chris

                        It doesn't matter.

                        Remember we are not looking at 'relaxation' and 'comfort' as the definitions that everyone is/was taught, ie to 'loosen' muscles etc.
                        Ideomotion is an example of what the brain has wanted to do perhaps for years and has been prevented from doing so by all sorts of constraints and commands from the external environment.

                        Nari

                        Comment


                        • #27
                          Hi Chris,
                          I treat with people either sitting or standing. I let the patient choose. I usually stand on a little stool behind the patient because I'm shorter than most, if they stand. I'm more comfortable with them sitting, but I don't let my own preference interfere with their choice. (Your post is hilarious by the way!) It's easy to elicit corrective movement isn't it? Even if you are only treating "a leg".. you can practically feel the brain going back to normal.
                          Diane
                          www.dermoneuromodulation.com
                          SensibleSolutionsPhysiotherapy
                          HumanAntiGravitySuit blog
                          Neurotonics PT Teamblog
                          Canadian Physiotherapy Pain Science Division (Archived newsletters, paincasts)
                          Canadian Physiotherapy Association Pain Science Division Facebook page
                          @PainPhysiosCan
                          WCPT PhysiotherapyPainNetwork on Facebook
                          @WCPTPTPN
                          Neuroscience and Pain Science for Manual PTs Facebook page

                          @dfjpt
                          SomaSimple on Facebook
                          @somasimple

                          "Rene Descartes was very very smart, but as it turned out, he was wrong." ~Lorimer Moseley

                          “Comment is free, but the facts are sacred.” ~Charles Prestwich Scott, nephew of founder and editor (1872-1929) of The Guardian , in a 1921 Centenary editorial

                          “If you make people think they're thinking, they'll love you, but if you really make them think, they'll hate you." ~Don Marquis

                          "In times of change, learners inherit the earth, while the learned find themselves beautifully equipped to deal with a world that no longer exists" ~Roland Barth

                          "Doubt is not a pleasant mental state, but certainty is a ridiculous one."~Voltaire

                          Comment


                          • #28
                            Thanks, Diane, that's a great introduction for me for next time with her.
                            I will post what happens when she comes in next.
                            Chris, glad to see you here....

                            J
                            Jason Silvernail DPT, DSc, FAAOMPT
                            Board-Certified in Orthopedic Physical Therapy
                            Fellowship-Trained in Orthopedic Manual Therapy

                            Certified Strength and Conditioning Specialist


                            The views expressed in this entry are those of the author alone and do not reflect the official policy or position of the Department of the Army, Department of Defense, or the US Government.

                            Comment


                            • #29
                              Glad to see you here as well Jason. It appears, per the little green box underneath the number of posts, that we are 'on a distinguished road'. I'm not sure what that means necessarily, but it sounds cool.
                              Chris Adams, PT, MPT

                              Comment


                              • #30
                                You know, Chris, I did not notice the little green box until you mentioned it.
                                Are we all on a distinguished road? Must check....

                                I used to think quite often that I was on a road to nowhere. with physiotherapy. At least now there are some signs up on the road, and I can forget the map more and enjoy the territory...

                                Nari

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