Another reason therapists don't know

[John W]

Well, to what extent do you think this is the case?

I've mentioned many times that I think our current epidemic of pain is rooted in the culture. Barrett uses the analogy of a fish being unaware of its aqueous existence; that is until it finds itself flopping around on dry land after being reeled in. So, to the extent that the culture has swallowed the biomedicalization of pain hook, line, and sinker, I would argue is the degree to which we should attempt to err on the side of caution when using manual interventions with patients.

I think it's important to remember the distinction between the patients who don't get well and those who do. Our instruments for measuring whatever these predictive psychosocial factors are- fear, self-confidence, coping- aren't quite sensitive enough yet to identify these patients in the crowd. Until they do, I think we are "treating" a lot of patients who likely don't need any treatment at all. But, they all dutifully attend therapy (why not, their insurance pays for it) and have their limbs yanked and their spines pressed on, and only by virtue of dumb luck and their genetic architecture do the vast majority leave the clinic in no worse shape than when they arrived. They are "better". They've met their goals.

I fear, however, that they might now become silent carriers- modern day Typhoid Mary's- of the "fix my pain" meme, who then pass it on to some poor soul who one day falls and breaks her wrist and ends up with CRPS.

We can't touch or move them at all.

[Johnny_Nada]

John W,

Your comments make me think of a few things.

I've seen manipulation be very successful….for people with symptoms that would never lead them to seek treatment…..i.e. physical therapists at con ed courses; "my back hurts, can you crack me (insert cavitation), ohhh so much better. This will work for my patients."

Is it fair to say there are two types of pain? One you can cope with and the other you can't?

One you can still live without suffering, the other that brings you to the doctor?

I can't help but think of all the people that have told me "I wouldn't be here if my doctor didn't send me." These are the same folks I would have called a success in private practice after they performed so well on all outcomes.

Can we say those that seek treatment for their pain already demonstrate some lack of confidence or self efficacy and have some sense of fear?

[PatrickL]

John,
Would you rather see a PT perform aggressive "art" like manual input (or some other coercive/passive technique) with a defensible explanation or a PT performing gentle / light touch with an erroneous explanation?

[Barrett Dorko]

Patrick,

As always, you're asking a good question and the responses have been both illustrative and relevant.

In return, I can't help but wonder how the therapist "knows" in which way to take the patient passively? How do they go about defending that decision?

[John W]

Wicked,
If you tell a patient that the origin of their pain is mechanical, isn't that just another way of informing them that they are moving incorrectly? My problem is not people with pain being told that they move incorrectly, rather it's when they are told that moving incorrectly caused their pain.

"Tough love" is not the best choice of terms. I was a bit lazy there.

Patients deserve to be told that their journey in the health system is liable to engender an external locus of control. They've been told a variety of inaccurate stories that have made them a recipient of procedures either designed to distinctly identify or fix their problem, yet we all know that almost never happens.

It's tough to provide this kind of care- the kind that attempts to move the patient's locus of control back to where it belongs. Some patients struggled with personal
responsibility long before their pain started, and my suspicion is that this might be a set up for increased risk of persistent pain.

I don't recall if you practice PT in the US, but I can assure you that providing care (with love, of course) has very little bearing on you business success.



John Ware, PT, FAAOMPT

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[John W]

John,
Would you rather see a PT perform aggressive "art" like manual input (or some other coercive/passive technique) with a defensible explanation or a PT performing gentle / light touch with an erroneous explanation?

Patrick,
You've offered me a false choice with that question. What is "art" like manual input? My patient who received ART told me that her psoas pain is gone, but she still has TFL pain. I'm pretty sure that you wouldn't recommend treating her TFL.


John Ware, PT, FAAOMPT

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[Evanthis Raftopoulos]

"My attempt to answer Barrett's question, the direction only matters after two people know how to touch each other."

Hi, can you explain what this means in the context of rehab? Not sure if I'm following your point. Thank you. -Evan


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[Evanthis Raftopoulos]

"In return, I can't help but wonder how the therapist "knows" in which way to take the patient passively? How do they go about defending that decision?"

Assuming no serious nmsk tissue pathology the question I like to ask: is there a movement limitation that is not pre existing, it is limited due to pain/guarding (not it just feels tight), and acknowledged by the patient (during hx taking/part of primary complaint)and verified by the practitioner (during examination)?

If the answers are yes, then 'hands on' passive or active assisted or resisted maneuvers with directional preference towards the lost ROM, may help facilitate movement /reduce defensive outputs. A follow up question I like to ask: will hands on treatment be superior in any way than hands off treatment? Why, or why not?if I don't see a justifiable reason why hands on can be superior to hands off for a specific patient/presentation, then hands off makes more sense to me. Of course things are more complex as there are many variables involve in decision making and it's not ideal to generalize the same exact clinical reasoning even for similar presentations.


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[Bas Asselbergs]

I want to add another aspect of ideomotion that seems to have fallen by the wayside in the comparison with choreographed motion.
Some ideomotor correction can be fully invisible.

I held a participant's ankle, then landed my hand on his diaphragm gently.
Nothing moved, yet, he felt softer, relaxed and started to begin to almost doze.

Characteristics of correction include warming and softening; there is no mention of increased motion.
Patients also need to know that.

[tal.b]

What is the difference between ideomotion and rhythmic/continuous withdrawal? If resolution requires instinctive movement, which is essentially ideomotion, to address the abnormal neurodynamic- why doesn’t our nautural response of withdrawal perpetuate and act in the same favorable response as ideomotion claims to? Withdrawal seem to me to be an active and instinctive movement in a direction that opposes the abnormal neurodynamic. Repetitive withdrawal, however, does not seem to be associated as a therapeutic tool. What is inherent to ideomotion that separates it from withdrawal?

[Johnny_Nada]

Bas,
Why do you call that ideomotion? Can we simply call that relaxation? I've had massages or instances where some one has laid there hands on my head and felt those things.

[Bas Asselbergs]

Because it is motion. The fibers in the tissues change length.
Self-generated change.

Blood is in motion in the smallest of ways, yet we do not feel capillary motion.
Constant activity in the spinal stabilizers, contract/relax. Motion without it being visible.
Relaxation is motion as well.

Tal, according to the pain science royalty, Patrick Wall, when threatened, we go through withdrawal, protection and resolution stages. Ideomotion helps in the resolution stage.

[tal.b]

Tal, according to the pain science royalty, Patrick Wall, when threatened, we go through withdrawal, protection and resolution stages. Ideomotion helps in the resolution stage.

it seems like ideomotion has a parasympathetic connotation, and withdrawal has a sympathetic connotation. When my back hurts, sitting in a chair i move more frequently (both consciously and unconsciously) and my tolerance to being still is poor. i am probably moving in ways that lessen the abnormal neurodynamic. it is instinctive, and active. what is Wall's definition of withdrawal? I dont think i feel a sense of warmth, and detectible lasting change in pain level as is frequently described in an effective SC tx. Barret has mentioned (from my understanding) that the hands of the therapist can be used to sense the direction in which the patient wants to move (want in an innate sense). somewhere between context, hands, and education, we arrive at an innate expression of movement that yields an increase in bloodflow, a parasympathetic shift, and resolution of symptoms. To be notable, i imagine this expression must be somehow more dramatic than that of me moving around in my chair when my back hurts...though im not clear on the difference or its mechanism.

[Bas Asselbergs]

Withdrawal is the pulling back of the limb or body part (or whole organism) from threat, followed by - if you will - splinting/bracing of the threatened part or whole organism (protection).
When you are sitting in a chair, are you fully attentive to what wants to happen with movement?
Or are you still trying to do what you were "doing" (TV, computer, reading, talking), and try to quiet the loudest interference/interruption from your nervous system?
Are you alone when this occurs? (If not,cultural mores, i.e. NOT acting funny can depress the expression of corrective ideomotion).
When you move non-consciously, do you attend to it to let it develop further?

Simply changing position can help one, but could be fully insufficient for another. It sounds like you might be the other. As I am.
I do not fully experience warming and softening and relief unless I "attend" to my ideomotion.


PS: with some practice it gets easier and easier to just let it "go".

[Evanthis Raftopoulos]

"All I was getting at is our internal processing while handling another accounts for our ability to determine how we will move them before what direction."

Thanks for clarifying, that's not how I read the original comment.



"I want to add another aspect of ideomotion that seems to have fallen by the wayside in the comparison with choreographed motion."

Bas, isn't all movement that occurs in the context of therapy in a way 'choreographed'?

"Characteristics of correction include warming and softening; there is no mention of increased motion."

Yes but ideomotion =\ equal correction by definition. I think that we are talking about something different.


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