Another reason therapists don't know

[zendogg]

I see what you are trying to tease out here.
I'd say "yes" to that.
In my opinion, there must be a central process to elicit any therapeutic and corrective motion.

We can NOT know whether the pain relief is from changes in mechanical tension (reduction of possible nociception), or simply a downregulation within the brain's emergent experiences.
The only thing that may help determine that is in the cases where ideomotion does NOT instantly relieve pain, but afterwards.

With regards to movement being necessary for pain relief: I firmly consider motion an essential factor in well-perfused and oxygenated tissues, which include those thirsty neural structures, as well as an essential factor in interoceptive feedback to the brain.

Motion helps our brain mapping, our self-awareness of where "things" are within ourselves. It does not have to be big motion, but any action within our systems IS feedback.

I can not help but think of the importance for infants to be able to move freely - without that, their development is severely delayed. A direct effect of motion on our neural activities and health.

A long winded ramble......Need coffee.

Bas,

I have been thinking a lot about this since my first visit to SS and had my expensive and involved techniques blown out of the water, not to mention a good chunk of my ego!
DNM made me think that perhaps because of the uncanny ability for a skin contact/stretch to reduce or even eliminate very tender points, it is enough for "central command" to conclude all is well (or better enough) to adjust protective patterns. Movement returns.

I have also felt that this step in therapy, the resolution, which I am suggesting is not a result of movement but rather the perception of the brain, has been the missing piece. You can throw all kinds of hands on or movement therapy that you like at a non-pathological pain patient and you may get lucky with a random context comment or by picking an exercise that is non-threatening enough. But the unlocking of the protection FIRST with DNM or soft hands on like SC, or education, it is the kind hands and demeanor that suggest safety, the system down regulates, movement of all sorts returns.

Nathan

[Barrett Dorko]

Removing an impediment to correction seems reasonable.

Maybe this will help.

[Diane]

Bas,

I have been thinking a lot about this since my first visit to SS and had my expensive and involved techniques blown out of the water, not to mention a good chunk of my ego!
DNM made me think that perhaps because of the uncanny ability for a skin contact/stretch to reduce or even eliminate very tender points, it is enough for "central command" to conclude all is well (or better enough) to adjust protective patterns. Movement returns.

I have also felt that this step in therapy, the resolution, which I am suggesting is not a result of movement but rather the perception of the brain, has been the missing piece. You can throw all kinds of hands on or movement therapy that you like at a non-pathological pain patient and you may get lucky with a random context comment or by picking an exercise that is non-threatening enough. But the unlocking of the protection FIRST with DNM or soft hands on like SC, or education, it is the kind hands and demeanor that suggest safety, the system down regulates, movement of all sorts returns.

Nathan

I agree.. and there are neurological reasons for that.
1. The brain, once a neurotag has arisen and become easily triggered, can't go back to being a brain that never had that neurotag. (I think of a neurotag as a tangled mess of enhanced firing, sort of like a positive feedback loop but more of a birds' nest than a simple loop)
2. Something new has to be added for the brain to get busy with. Manual contact provides it a way to distract itself from the unfortunate neurotag, long enough to get itself started on building a new representation of somatic "reality" - a new neurotag.
3. The old one will never go away, but the brain can now "choose" to adapt itself to the new one. It's called extinction learning and happens at the receptor level of brain operation. Once that happens, old triggers are no longer triggery.
4. Add a novel stimulus, e.g., skin stretching (see Gandevia and Collins 2005), allow the brain to enjoy a movement illusion.

Illusory movements were evoked at the interphalangeal (IP) joints of the index finger, the elbow, and the knee by stimulation of populations of cutaneous and muscle spindle receptors, both separately and together

5. This will engage the dorsolateral prefrontal cortex, even. (See Lundblad et al 2010, about Ruffinis and DLPFC)
6. If you already have the patient's DLPFC primed with some pain ed, you'll be able to get it to focus on skin stretch/ruffini input.
7. Even if you think you have to mobilipulate people (i.e., engage in manual therapy overkill), you still have to properly set a patient's expectation, because no matter WHAT you think you're doing, it still all boils down to non-specific effects being the crucial variable.
8. Non-specific effects is the term used when the word "placebo effect" is too contentious.

[zendogg]

Barrett that is a great article.

Diane, awesome explanation!

[Evanthis Raftopoulos]

"But the unlocking of the protection FIRST with DNM or soft hands on like SC, or education, it is the kind hands and demeanor that suggest safety, the system down regulates, movement of all sorts returns. "

I think this sounds attractive in theory, but how do we know that we are not just telling stories here? In the absence of clinical trials to look at outcomes, and in the absence of falsifiability, I can see many in the scientific/medical community dismissing both SC and DNM as wishful thinking. I'm not being too critical, I'm only applying the same standards as when criticizing any other method that claims to treat painful conditions.


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[Diane]

"But the unlocking of the protection FIRST with DNM or soft hands on like SC, or education, it is the kind hands and demeanor that suggest safety, the system down regulates, movement of all sorts returns. "

I think this sounds attractive in theory, but how do we know that we are not just telling stories here? In the absence of clinical trials to look at outcomes, and in the absence of falsifiability, I can see many in the scientific/medical community dismissing both SC and DNM as wishful thinking. I'm not being too critical, I'm only applying the same standards as when criticizing any other method that claims to treat painful conditions.


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Yup.
Sad but true.
Generations of people have died trying to "prove" that manual therapy "works" - they've become so wound up in trying to turn interactive verbs into some kind of reproducible and measurable noun that they kill themselves (and actual patients) trying. Metaphorically speaking.

It will never ever ever ever happen (a conclusive evidence base for manual therapy).

(Jason will disagree with me probably for using such conclusive language, like he did last time.)

Here is my little list:

1. Do no nocicepting.
2. Don't kill your patients.
3. Less is way more.
4. Manual therapy belongs forever sandwiched between pain education before, and movement therapy after.
5. Nothing in life is certain
6. There are some patients who will be made worse by physical contact, not better. Learn to spot, then avoid handling people with hyperpathia/wind-up pain.
7. Don't use manual therapy of any pretentious mobilipulating kind on babies. For Pete's sake.
8. Be as interactive as possible, not operative. Ask for feedback and use it to guide your handling.

[John W]

Evan,
The medical community generally embraces RCTs based on an utter lack of theory, so I'm doubtful that clinical trials demonstrating efficacy of SC and DNM will have much of an impact against the mounds of tooth fairy science stacked against it- at least within our lifetimes.

Call me cynical, but I think there's very little reason to think that science drives clinical practice. The schools tell students this and pay a sort of lip-service to something they call "evidence based practice", but that's all it is. DPT students do not graduate with anywhere near the scientific literacy required to be a critical-thinking clinician.

We all know what drives clinical practice for treating pain, and it ain't the science. So, we'll have to be content with "telling our stories" until the whole thing collapses.

[Jo Bowyer]

7. Don't use manual therapy of any pretentious mobilipulating kind on babies. For Pete's sake.

There is no need, they move for themselves. All I do is lift them off what ever surface they are on and allow full expression of movement until they settle. I don't mind getting my fingers chewed if someone is teething and the chewing stops when the finger comes to rest in the right place. The baby is in charge of the session and it is the practitioner's function to pay attention and make sure that they don't interfere with a nervous system that 'knows' what it is doing. Anyone dealing with babies should know infant red flags and it has been enormously helpful to me to have had a few years dealing with them in a hospital setting.

[Chunk]

3. Less is way more.

5. Nothing in life is certain

8. Be as interactive as possible, not operative. Ask for feedback and use it to guide your handling.

YES! :clap2: I can't remember who said it but "the only certain thing in medicine is uncertainty"

[Josh]

Since everything is uncertain including consciousness/unconsciousness/subconsciousness, can we just simplify everything and say educate and encourage Movement. Thats it, not ideomotion, conscious motion, volitional motion, choreographed motion, just Movement....because we can't really be sure of where, when, or how it happens. But we know it is vital for resolution of mechanical pain.

As long as well don't spread crappy information as to why things happen

[Jo Bowyer]

Since everything is uncertain including consciousness/unconsciousness/subconsciousness, can we just simplify everything and say educate and encourage Movement. Thats it, not ideomotion, conscious motion, volitional motion, choreographed motion, just Movement....because we can't really be sure of where, when, or how it happens. But we know it is vital for resolution of mechanical pain.

As long as well don't spread crappy information as to why things happen

can we just simplify everything and say educate and encourage Movement.

We could.

ideomotion, conscious motion, volitional motion, choreographed motion,

All of these have the potential to help familiarise the patient with the workings of their own nervous system.

As long as well don't spread crappy information as to why things happen

I am grateful to a colleague who helped a patient of mine today who was distressed by thoracic pain and felt unable to wait until I am next in London. I am fairly p****d off by the fact that he apparently told my patient that he had put his rib back into place. The treatment soreness following the manipulation will settle, the meme is likely to persist

[zendogg]

Since everything is uncertain including consciousness/unconsciousness/subconsciousness, can we just simplify everything and say educate and encourage Movement. Thats it, not ideomotion, conscious motion, volitional motion, choreographed motion, just Movement....because we can't really be sure of where, when, or how it happens. But we know it is vital for resolution of mechanical pain.

As long as well don't spread crappy information as to why things happen

As far as I can tell, that is at the forefront of the SS reason for existing. Get the client to understand the situation, including respect for possible pathology, minimize catastrophization, provide as much of a context that someone's OWN system get feel safe enough to begin restoring function. We educate to be less concerned about waging war on pain, we introduce the patient to graded movements toward goal activities while responsibly educating on recovery expectations. Finally, we provide some input with our hands, maybe, that offers the inner sentinel a reason to trust that movement can resume. Repeat.

I don't think the goal has ever been to make any particular technique the next miracle. Only to provide a least wrong explanation of what physiological and "command center" effects it could have. While at the same time exposing the long standing horse poo of therapist technique glorification.

Nathan

[Jo Bowyer]

I have it in my head that the culture at the time restricted this. This was the midst of the Victorian Era. At least, that's my story and I'm sticking to it.

If this is a reference to restriction of ideomotion during the Victorian Era, the following comes to mind:

Rigid class distinction, mind your ps and qs. Clothing- stiff collars and corsets for gentlemen, corsets and tight lacing for ladies, sub 20" waists were not unusual, fabrics were stiff and buttons required button hooks to get the job done, woe betide you if you spill anything on your clothes (no washing machines).

Marital relations: "Lie back and think of England" and remember, "A lady does not move!"

Children and servants should be seen and not heard, under servants should be seen as little as possible, babies should be swaddled.

Military bearing,sometimes involving corsetry, the position of attention.

Deportment lessons for young ladies,sometimes involving iron braces and corsets as well as books on the head. Standing in the corner wearing a dunce's hat, if you moved it fell off which would earn you a beating.

[PatrickL]

The effort required to educate the patient that "no, my special skills are not really needed for you to do this" appears to be greater with choreographed/guided movement (by us, the experts) than by auto-correct.

I disagree. One could state something like "you shouldn't need to come back and see a physio regularly... I'm going to teach you some movement strategies to integrate into your life that should have the effect of reducing/resolving the guarding in your system that I suspect is the major driver of your symptoms."

The patients perception of us (PTs) having manual handling expertise is not reduced or diminished by the provision of lighter/non coercive touch. It's reduced by the explanation we provide.

[PatrickL]

Barrett, do you think the provision of passive motion by a PT necessarily prevents an ideomotoric transition from protection towards resolution?