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  • Why is passive movement of value?
    Of value for what purpose? Of value relative to what?

    I argue that passively applied movement is no less likely to catalyze an altered motor output from protection toward resolution than a non-coercive touch, and no more likely (given appropriate education and context setting) to steal away the patients locus of control.

    Comment


    • Patrick,

      You say that passive movement (decided upon and elicited by the therapist) is "no less likely to catalyze an altered motor output from protection toward resolution..."

      You don't think the patient notices the culture around them?

      Bas,

      I think we can agree it is about 45 minutes. I DON'T demonstrate any handling before then. In fact, I specifically say, "The therapist should understand some things about what neuroscience has taught us about pain first."

      Still, people think I just walk into the patient's peripersonal space and touch them. That's not true.
      Barrett L. Dorko

      Comment


      • You say that passive movement (decided upon and elicited by the therapist) is "no less likely to catalyze an altered motor output from protection toward resolution..."

        You don't think the patient notices the culture around them?
        This looks like a non sequitur to me. Perhaps you can further explain how you arrive at the conclusion that I don't think the patient notices the culture around them?

        Comment


        • Still, people think I just walk into the patient's peripersonal space and touch them. That's not true.
          Which people are you referring to?

          Comment


          • Patrick,

            I am referring to all the therapists who think, claim and insist that I "just teach another technique." It's a large group.

            When a therapist moves a patient passively isn't the patient assuming that the therapist has a reason for this? Do they (the therapist) have a rational and defensible premise they can state?
            Last edited by Barrett Dorko; 14-05-2014, 04:21 PM.
            Barrett L. Dorko

            Comment


            • And as far as I know, we don't have any evidence comparing the usefulness of these three broad approaches for catalyzing this altered motor output.
              We don't have evidence that any particular method is more useful or effective with these patients. We only have our understanding based on the current available science.

              We don't even know if the altered motor output precedes or follows decreases in a pain experience (since it's likely cyclical).
              We have indirect evidence of motor output changes occurring after pain education in the form of increased ROM (Moseley, Nicholas and Hodges, 2004). According to the neuromatrix framework, it's not so much matter of when the motor output changes occur as it is at what level of processing that they occur. The pain output is depicted at the top of the diagram because it represents the dominant perception- the pain neurotag- that drives motor and neuroendocrine responses, which are shown in sequence below it. My understanding of this is that there are characteristic motor and endocrine responses associated with the pain neurotag. If the pain didn't exist, then these motor and neuroendocrine/stress system responses would not exist as such, thus they are contingent upon the pain neurotag. Therefore, any alteration in the pain neurotag would necessarily result in some change in motor output (and stress system responses), which would then feed back into the neuromatrix. I speculate that the new adaptive motor (and stress) response provide negative feedback to the pain neurotag via a reduction in disinhibition, i.e. widespread involvement of areas of the brain that are not normally associated with a pain perception, including in the sensory and motor cortices (i.e. cortical "smudging").

              So, I think it's reasonable to conclude that any adaptive change in motor output is due to an alteration in the pain neurotag.

              The argument for non coercive touch is based on the assumption that lighter touch ensures that greater locus of control stays with the patient.
              I'd argue that the promotion of locus of control is only one important factor to consider when employing manual therapy. But, I think Diane has also persuasively argued that providing the neuromatrix with an input that "reminds" it of movement via skin stretch is also important. I also think it's based on a sound scientific premise. In the graded motor imagery approach, Moseley and Butler talk about the progression from implicit (laterality recognition) and then explicit (imagined movements and then mirror therapy) motor imagery. The rationale of moving from subconscious movements to conscious/planned movements is based on selectively activating the pre-motor cortex and then gradually bringing in the motor cortex in a graded fashion. I think it's reasonable to speculate that stimulating mechanoreceptors in the skin would be a way to provide non-threatening activation of the motor cortex, and I would also argue that it is much less likely to inadvertently activate the pain neurotag.

              I am becoming increasingly convinced that all these various persistent pain problems that have a mechanical origin are different degrees of the same problem, which is abnormal or maladaptive sensitization of the nervous system, than discretely different kinds of diseases.
              The mechanisms in the periphery manifest differently based on genetic architecture and biochemical profiles, but in essence the problem is in the brain.
              Last edited by John W; 14-05-2014, 09:55 PM.
              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

              Comment


              • Premise for passive movement:

                If the underlying assumption through eval is that we are dealing with an abnormal neurodynamic, then together with the patient's feedback, we explore some ranges of a movement. There is no attempting to make a limb behave in a particular way. The patient is asked to provide their "sense" of the movement; does it bring up fear, does it feel tight, stuck, etc? We now have a subjective presentation of how that movement is represented to them. This can be an area where some TNE is effective.
                As has been stated, outside of anesthetization there is no such thing as passive movement. Muscles contract and lengthen providing possible decrease to abn. Nd.
                Contact with skin during movement provides sensory feedback akin to DNM.
                Therapeutic alliance during movements that are safe (as determined through a proper context setting prior to initiating any movement) could allow for added self exploration of movements and muscle contraction and/or lengthening.

                Nathan

                Comment


                • Nathan,

                  You seem to be doing something driven by the patient's sense of what's happening as you do it. I'm confused. Is there a method in there somewhere? A premise?

                  I also sense that I wouldn't use this method, and I don't know what it is anyway.

                  What's TNE?
                  Barrett L. Dorko

                  Comment


                  • Originally posted by Barrett Dorko View Post
                    Nathan,

                    You seem to be doing something driven by the patient's sense of what's happening as you do it. I'm confused. Is there a method in there somewhere? A premise?

                    I also sense that I wouldn't use this method, and I don't know what it is anyway.

                    What's TNE?
                    No, I am listening to the person, hearing what they think about a particular position/movement.
                    I am not creating a method, simply making a statement of how passive movement could be used from an ectodermal point of view.
                    Therapeutic Neuroscience Education - Adrien louw.

                    Comment


                    • Personally, I find that listening to a patient's verbiage is unreliable.

                      There is always the risk of the patient's assumption that any increase in pain is nontherapeutic (it isn't always) and then there's their misinterpretation of increased muscular activity. Would they assume that the increased activity of the muscles that drive speech is a warning not to speak? How are those muscles different from others?

                      Moving others passively (and I know the concept is problematic) presumes that the therapist knows which way to go and when that doesn't work out especially well either through no lasting response or increased report of pain, the patient's report of what they think is placed in the mix.

                      There's a premise in there somewhere but it certainly isn't one I would choose and the method chosen is indefensible.
                      Barrett L. Dorko

                      Comment


                      • I left out of my last comment another very important aspect of non-coercive, light touch that is based on broader evolutionary theory. Primate social grooming is a widely accepted theory to explain light touch among lower primates. It includes non-erotic contact for the purpose of social interaction, showing care and affection, calming a troubled member of the troop, and I'm sure more purposes than I'm unaware of. When other mammals play, on the other hand, they can get pretty rough with each other, and pull, yank, and squeeze each other. However, it wouldn't make sense for this kind of behavior to occur when an individual is injured or even not in the mood to play.

                        It almost seems like our pushing and pulling on patients is analogous to some little boys trying to coax their friend who's not feeling well to come outside and play by grabbing him by the arm and pulling him out the door. Now it could be that the boy who didn't feel well just needed a little push to get moving and end up enjoying himself. But, it also might be that he's really not well, and running around playing outside will just make him feel worse. If this is our patient, can we predict in any rational way which outcome will occur? Maybe only if the patient indicated to us that "it worked" before. But then we are still compelled to provide accurate education. Once that is provided, will that coercive intervention still work like it did before, or has the bubble been burst? How do we know? I wrestle with these questions everyday in the clinic.

                        The main biological attribute that makes us different from lower primates (a little boys ) is our huge forebrain, which is both a blessing and a curse. We are capable of amazing and beautiful things with this brain, but it can get itself and the organism that it monitors into trouble when it's perception of threat persists even after the threat no longer exists. Ironically, we have to use that same forebrain to figure out how to get it out of the mess it got itself into.

                        Patrick, I think focusing on just the locus of control argument with respect to non-coercive forms of care for non-pathological pain short-changes what Diane and Barrett have been writing about for many years.
                        Last edited by John W; 15-05-2014, 12:22 AM.
                        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

                        Comment


                        • Blaise asks:

                          Could you explain why this is not an operator stance?
                          I suppose you could say my interpretation can be seen that way. But I know that muscular activity is often misinterpreted and understandably so.

                          I wrote about that here.
                          Barrett L. Dorko

                          Comment


                          • When a therapist moves a patient passively isn't the patient assuming that the therapist has a reason for this?
                            I would hazard a guess that a patient would assume that the therapist has a reason for applying passive movement. It's incumbent upon the therapist to provide a defensible reason, in my view. Anyone applying a passive movement technique, or any form of manual therapy could reasonably defend the application of their preferred method by explaining to the patient that
                            their symptoms have emerged as a result of sensitization of the sensory pathways and processing regions of the brain that deal with threat information, and a subsequent output of defensive muscular activity.

                            The passively applied movement can be explained in terms of novel and non threatening sensory/discrim input. Explaining the input in terms of it being non threatening precludes a PT from using aggressive handling.
                            Do they (the therapist) have a rational and defensible premise they can state?
                            Again, I don't know who the "they" is you're referring to? Are you lumping every PT who uses passive movements into one category called "they"? I can't speak for these people, but I can, and I think I have made a strong argument for the use of passive movement in conjunction with appropriate education and context setting.

                            Implicit in the resistance to what I've been arguing for here (I've been arguing that we don't know enough to make claims about whether light/non coercive touch or passive movement or active/conscious movement is most defensible), is an argument that methods that utilize light touch and are non coercive are the most defensible methods. I don't see any compelling reasoning to support that claim.

                            Comment


                            • Originally posted by Evanthis Raftopoulos View Post

                              Hi Gilbert, on the one hand you are implying that active movement is necessary as a form of treatment in order to facilitate ideomotion, but on the other hand you suggest that DNM can facilitate ideomotion. If DNM can facilitate ideomotion, then why not any somatosensory input including needling or any form of massage or manual treatment?

                              I’m going back to the definitions again, ideomotion is small movement that we are not aware of thought to be generated by expectation/idea/belief.

                              ...

                              How do I elicit non-volitional movement? This sounds like an oxymoron to me.
                              I totally disagree with your definition of ideomotion here. Where do you get the "small movement we are not aware of" idea?

                              RE: How to elicit ideomotion in yourself, I can only say what works for me. I need to be alone, relaxed (standing is fine) and then 'give permission' to just wait for movement to start. A light manual contact of my hand over a bony prominence as Barrett has suggested does help. Waiting patiently and 'doing nothing' volitionally are the hard part.

                              What it feels like to me: If you've ever done the trick of standing in a doorway and pushing out isometrically with shoulder abuction for a minute, and then moving out of the doorway so your arms rise up by themselves, you know the feeling. There's a reason Barrett includes "effortless" and "surprise" as two of the characteristics. I laughed out loud the first time, as I think others have.

                              Comment


                              • Moving others passively (and I know the concept is problematic) presumes that the therapist knows which way to go
                                No it doesn't.

                                Comment

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