Uncertain Consequences - Revisited

[Barrett Dorko]

I’ve spent some time recently looking through some of the archived threads in Barrett’s Bullypit, which began as an ongoing discussion of neurogenic pain and its management with David Butler in February of 2001 on Rehab Edge. To me, this writing is a treasure trove of original thinking and innovation. There was no hesitance on the part of those participating (many of whom have moved here to Soma Simple) to speculate and then support their thinking with references you won’t find anywhere else. As with this site, sharp questioning of those who proposed methods of management they couldn’t support was common, but when Rehab Edge became a purely commercial venture and these same therapists threatened to withold their advertising dollars unless I was made to shut up - well, you know what happened next.

The reason I bring all of this up is because one specific thread, The Consequences of Uncertainty, contains writing from several regular contributors to this site that, I think, can lead us into another fruitful discussion regarding the abnormal neurodynamic – its presentation, prevalence and confounding nature.

I want to both re-examine and expand upon what was said there. After listening to Michael Shacklock last week I am increasingly convinced that unless the therapy community looks deeper into instinctive function we will struggle unnecessarily with many patients who have no hope of finding help from those who don’t. I’ve had an analogy that includes the telegraph and the Pony Express in my head for a while I want to use here as well, but I’ll wait a bit on that.

Let’s begin with a line inspired by the original thread:

In Michael Shermer’s Science Friction he writes that the anthropologist Bronislaw Malinowski discovered that the level of superstition among Trobriand Island fisherman depended upon the level of the uncertainty of the outcome-“the farther out to sea they went, the more complex their superstitious rituals became.”

The proposed methods of both Shacklock and Butler contain an emphasis on very careful and precise manual coercion not normally seen in other passive modes of manual care. They appropriately appreciate the sensitivity of the system they seek to change and are well aware of the fact that they might easily elicit motion in the wrong direction. Indications of improvement are sought from the patient’s expression and function that may or may not be reliable or valid. It is almost as if the uncertainty present in the practitioner’s mind is reflected in their practice – an uncertainty not commonly seen in “mesodermal” disorders.

Is it possible to reduce the uncertainty that commonly accompanies this sort of care by looking deeper in the system for instinctive responses to neural compromise? Are those who teach coercive methods able to change in this direction? If not, why not?

[Diane]

I think I get what you're asking here Barrett. If there were a series of rules to follow that would make the nervous system one was treating more visible to one's kinesthetic perception, more agreeable to one's presence, and more willing to follow a treatment plan you've got in mind, it might be,

1. land lightly,
2. let the nervous system have time to welcome you,
3. wait for it to invite you to make your next move.

There is a 3 or 4 pound live perceiving creature (nervous system) embedded within the "meat" or the mesoderm. It is that live filamentous creature we treat, not the meat it enlivens.

[Barrett Dorko]

Reasons for the rules:

1))Weber-Fechner. If the therapist lands in any other way the threshold of sensitivity to sensory excitation (the deforming of the skin) is raised, making the patient’s sense of their own inclination difficult to, well, sense.

2)See Libet’s Mind Time. There is a slight delay between the unconscious inclination to act, the conscious awareness of that act and the act we can see or sense otherwise. If you don’t wait a bit you’ll miss that.

3) New stimulation leads to new change. Bobath called it “the three second rule.” If you’re not getting what you want after three seconds you should change your contact.

[Mike Terrell]

Diane,

The questions you will be asked by the mesodermalist with precise (black & white) rules of treatment would be:

1) what is "lightly"? How many pounds of pressure should be used?

2) What signs point to me being "welcomed"?

3) What is "the next move" (being specific regarding direction/time/force/etc.) and how do I know when the nervous system has "invited" me?

This is what you will be asked by PTs young and old and they will be looking for direct answers that don't require further thought. I think Barrett will back me up on this one.

mike t

[Barrett Dorko]

Mike,

You're right. I try to answer without being too vague/sarcastic/impatient/pedantic or rolling my eyes.

Not that I'm successful or anything.

This thread will, I hope, further build my case, especially the part about the Pony Express.

[nari]

Mike, you are so spot on. I can hear those questions, and the gentle shuffle of feet and thoughts away to something in one or two colours and not twenty.

Nari

[Diane]

Hi Mike,

1) what is "lightly"? How many pounds of pressure should be used?

Nothing in the pounds at all. Maybe a few ounces at most. The point is to entice, not oppress, the creature inside the creature, the organism inside the organism. You don't want to be pressing so hard that you can't feel with your own Ruffinis and Merkels all the physiology that goes on in response to your being there. That's really why you are there, to help the nervous system of your patient change itself. That's really why people like us exist at all, to help nervous systems change themselves through every possible avenue, through every possible means, e.g., education, CBT, all that stuff, including through kinesthetic means, i.e. contact that physiology and feel it shift under your hand. Provoke it but gently and it will have the freedom to respond maximally.

2) What signs point to me being "welcomed"?

Barrett's 4 characteristics of correction will be palpably present: warming, softening, surprise, effortlessness.. The patient may experience this consciously or it may be that only you the practitioner will feel parts of your patient's body expressing them.

3) What is "the next move" (being specific regarding direction/time/force/etc.) and how do I know when the nervous system has "invited" me?

The "next move" is to move on to some other part of the body. Which part can be somewhat planned in advance, but don't stick to the plan rigidly. If you need to make a side trip to a different area of body than was on your treatment plan that day, give yourself enough time to do that. This next part of the organism that needs attention will reveal itself in the moment; it may already be on the itinerary or you may feel you need to go there to see how it's doing, or the patient may ask you to check it out. Just stay interactive with that person's nervous system, and your own, and all will work itself out in exactly the best way possible. There are many possible best ways. Don't place artificial or arbitrary limits. The only really appropriate limits to set are therapeutic boundaries and time limit.

The time to make the next move will be when the organism inside the organism stops responding. Then move on and see if it will play some more. Do this until the session time is over.

If that isn't clear enough, then .. I don't know what else to say, except that 50% of all people are below average intelligence.

[Gil Haight]

Barrett
[QUOTE
Is it possible to reduce the uncertainty that commonly accompanies this sort of care by looking deeper in the system for instinctive responses to neural compromise?
Good question. I think the whole idea of uncertainty becomes almost irrelavant when talking about idiomotion. Since the origin of the movement is non-conscious, how can we ever be certain what it will be? Last week I was asked by a supervisor to describe what screens could be established to identify those pts who will respond favorably to my treatment. I answered by identifying the opposite. I generally get lousy results in those pts. who are certain they know what is wrong.
Gil

[Barrett Dorko]

Gil,

Would it be wrong to be "certain" that instinctive movement is always corrective?

I worry about patients that can't imagine they could know what to do without direction, but as the years pass I find that those sorts reduce in frequency - so I feel I was projecting this in my (relative) youth. Still, they will never disappear entirely.

This I know: Predicting any patient's ability to change on the basis of their intelligence, age, gender, social status, employment or general attitude when they sign in is unfair and often a mistake. It is the accuracy of the essential diagnosis that helps predict response and outcome - and that's not always certain either.

[Bas Asselbergs]

Gil, you're right in a sense, but I tend to think that it is NOT the predictability of the movement, but the predictability of the reaction/effect of the motion that may be determined - i.o.w.: the instinctive responses are extremely individual and varied, but the general effects can be classified I think.

I thought that Barrett's "this type of care" was referring to Shacklock and Butler's approach: with "emphasis on very careful and precise manual coercion (...)". If that is indeed the case, the way to take the uncertainty out of their approah would be to embrace the concept of ideomotion and NMD, and fully accept the non-control we have over the self-correction of a human system.
So, we step back and examine the issue of control in our approach, and what it's place is, and whether it should even be there....Pervasive in our PT-working-mind....
We (PTs) tend to think our effectiveness is in direct relationship with our control over the therapeutic process (we did start as the exercise-coach and modalities-operating person) - check out the issues PTs have with non-compliance in HEPs - and yet, there is NO study I know of that supports the notion.

A bit of a ramble - and I may be missing the point of the thread altogether.

[Gil Haight]

Barrett,
I think it was Thomas Hanna who said that somatic data need not be compared to any standard or model as it is immediately factual. No comparisons or judgements are neccessary. Those requiring direction simply can't see this. As has been discussed here before, Morris (Culture of Pain) believes this is a recognizable consequence of technology.
I can not agree with you more on your prediction rule (lack thereof) based on socio-demographics.
Gil

[Luke Rickards]

Barrett,

Until I had seen ideomotion at work (in many different pain presentations) I don't think it was possible to fully appreciate the significance of what you are referring to here.

I say this with particular reference to the altering of technique according patient responses during treatment common to all coercive methods. Too many times now I've worked with patients presenting with signs of radiculopathy and hard neurological impairments who consisently move into positions that increase neurological compromis and therefore symptoms and signs, and yet report feeling improvement immediately after, and consequently recover well.

If I were to coerce someone into a position that resulted in this kind of response then uncertainty(fear) of damage would immediately cause me to change my approach - and we would both miss out on something.

Luke

[nari]

Interesting thoughts. Once, PTs were recognised for pushing into pain until the patient got better - or worse. Then the backoff began - avoidance of pain altogether and working , still coercively, within painfree ranges. Neither achieves a consistent response that is satisfactory for the patient.

Bas,

I think the notion of 'needing' control over the patient's status is a crucial point. The tendency to think that PTs actually control whether the patient gets better - or worse- is rampant. This aspect alone may account for the failures to improve; along with the dreaded word "noncompliance".
It should be compulsory for PTs to spend some months in a pain clinic where the effort of trying to exert any control of any kind over the patient is fruitless and frustrating. It really brings home the message with a jolt, just how coercive we are with techniques and words in order to impose control.
Yet we are unaware of this; it seems to be written into the duty of care bit like a tattoo on the brain.

A quote:
Patient: (after pain education) Yeah, so this pain is real. That's good. I'm not looney. Like, no-one knows this pain..my pain. So how can they possibly help me? How can they pretend to know what it's like? All day, every day for 15 years...

Luke
I'm envious of your success. (How's that for jargon).

Nari

[Barrett Dorko]

Nari,

This patient is right - no one else can know his pain. While emotional pain might elicit an accurate and appropriate empathetic response from others physical pain isolates us. This is the subject of my essay Why the movie Cast Away is precisely about my work.

Scarry puts it this way in The Body In Pain, “Though the capacity to experience physical pain is as primal a fact about the human being as is the capacity to hear, to touch, to desire to fear to hunger it differs from these events and from every other bodily and psychic event by not having an object in the external world. Hearing and touch are of objects outside the boundaries of the body, as desire is of x, fear is fear of y, hunger is hunger for z; but pain is not of or for anything-it is itself alone. This objectlessness, the complete absence of referential content, almost prevents it from being rendered in language..."

The message I try to impart to my patients is this: "You need to perform creative acts in order to re-make your world. Here's one way." That's when Simple Contact followed by enhanced ideomotor expression comes in handy.

[Barrett Dorko]

I’d like to return to the original theme of this thread – the uncertainty surrounding the movement that will resolve an abnormal neurodynamic and how that uncertainty has made coercive manual care problematic.

At present, the best known methods of management for these problems include the intricate and careful passive positioning and movement described voluminously by Butler and Shacklock. The movement itself is both active and passive, occasionally uncomfortable and often pursued painlessly. I wave the books written by these therapists above my head when I teach and always encourage my students to buy them. I also make it clear that though I revere the thinking these therapists have done, I don’t employ their techniques of management – not at all.

In 1860 the looming Civil War made communication with the US west coast crucial for a number of reasons. At the time, the fastest way to do this was the stage coach which often took a month to complete the one way journey from Missouri to California. Seeing this, a couple of men conceived the Pony Express; a series of solitary riders on horseback supported by relay stations with fresh mounts and riders who were able to carry packets of mail over the same distance in about ten days. This was a well-paid but dangerous job. Famously, a recruitment poster detailed the rider’s attributes (no one over 125 pounds) and added, “orphans preferred.”

The Pony Express operated for about 18 months, generating an entire lore that captured the imagination of a nation. It ended virtually overnight.

In 1825 William Sturgeon built the first electromagnet and ten years later William Morse proved that signals could be transmitted over a wire by using the principles of electromagnetism; one of the four known forces in the universe. Thus the telegraph was born. Though Morse successfully demonstrated the accuracy and usefulness of this device, it took five years for Congress to appropriate funds for the first telegraph wires to be strung. This delay was a reflection of the public’s apathy.

When you ask people what ended the run of the Pony Express most say “the railroad,” but they’re wrong. It was the completion of the telegraph line to California. The railroad line wasn’t connected for another eight years.

Without beating those reading this over the head with the analogy I want to say this: The most popular methods of manual care currently proposed for neural mobilization remind me of the Pony Express. They’re certainly faster than the “stagecoach” techniques of stretching and traditionally choreographed movements that the Mesodermalists have employed for decades and they contain a specificity that should be admired. In addition, the therapist often adopts a certain “heroic” stance and is revered for their intricate knowledge of neuroanatomy and physiology. I feel that’s appropriate. But the uncertainty inherent to the passive or choreographed movement of the nervous system is reflected in the incredibly intricate approach to the procedures themselves and the often (in my experience) questionable progress seen. In effect, hostile Native Americans are around every corner.

Then we have the far less coercive approach of Simple Contact (or whatever it is that Diane is calling her gentle contact with the skin these days). This seems much more like the telegraph operator sitting in Missouri, sending a massage to another operator in California. The lines to send the electromagnetic signal are in place and the people at either end know the code. The speed of this message far exceeds any pony, and there’s no danger present.

Unfortunately, as of today, public apathy remains.