Another reason therapists don't know

[PatrickL]

Sorry for that abrupt response Barrett. I meant to come back and expand a little.

I dont think the application of passive movement is defensible if the intent of the PT is to move the patients limb in a corrective direction eg a PT who decides to mobilize the right c4 on c5 into extension and ipsilateral side flexion/rotation because he/she theorizes that this movement will restore normal mechanics, diminish tissue strain and resolve pain. Passive mashing of imagine trigger points is also indefensible. Passive stretching of muscles with the aim of resolving tightness and therefore resolving pain is indefensible... I could go on and on about the various indefensible applications of passive movement. Each is indefensible because of the PTs erroneous understanding of what role their manual handling plays in any observed changes in symptoms. In these cases (and I'm sure there are other examples) I agree that the use of passive motion follows from the PT's "knowledge" of the type/direction of movement required to "fix" the patient. Passive movement applied from an erroneous understanding no doubt dominates our profession.

But applying passive movement does not necessarily mean the PT is operating under delusions with regards to knowing the corrective movement path. I think a PT can move a patient passively in an explorative fashion, under the understanding that the goal is to provide novel and non threatening input, along with appropriate education about the neurophysiology of pain, non conscious motor output (withdrawal,protection,resolution), the role the culture plays in inhibiting movement etc.

[Barrett Dorko]

Patrick,

Well put. Because of answers like that, this thread has helped me immensely.

I'm pretty sure I, as the therapist, do my best to passively move the skin, and, pretty much, the skin only. Is that fair to say? By that I mean "is it possible to only move the skin?"

[Diane]

I'm pretty sure I, as the therapist, do my best to passively move the skin, and, pretty much, the skin only. Is that fair to say? By that I mean "is it possible to only move the skin?"

Pretty sure. Or maybe, skin organ. It's pretty hard to move the boat only upon the water, when the boat (cutis) in this case is firmly attached to the water (hypodermis) itself.

[Barrett Dorko]

Isn't the motility of the skin variable? That's why I wrote this.

Anyway, wouldn't the fractal nature of the structure preclude prediction?

[John W]

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

Well that flies in the face of the "bottom up" hypoxic peripheral nerve story. Ie altered motor output relieves mechanical deformation on neural tissue, thus reducing what might be a primary driver of threat processing for a given presentation of pain.

How so? In the case of DNM, it's hypothesized that stimulation of skin mechanoreceptors catalyzes a change in the pain neurotag, then motor output is altered since it is contingent upon the pain neurotag. Any enduring relief is attributable to a combination of adaptive changes in the periphery (sensory-discriminative input) along with learning (cognitive-evaluative) and stress system (motivational-affective) responses.

"Mechanical deformation" as an origin of pain is not entirely explained by peripheral events. I think it's an accurate explanation for any ongoing nociception, but certainly it's not a self-perpetuating "issue in the tissues". That's what trigger point proponents argue, and I think they are wrong.

In Shacklock's book, he essentially ignores the brain's influence on his concept of "neurodynamics", but this quote from p15 provides what boils down to a confession:

The proposal that mechanics and physiology of the nervous system are interdependent forms the basis for the concept of neurodynamics (Shacklock 1995a). Acceptance of this idea enables the clinician to take into account, not just the effects of mechanical changes on neurological function, but also pain mechanisms. In doing so, the clinician then has access to the central nervous system and biopsychosocial aspects of pain and disability which, although not covered in this book, are essential in the management of the person in pain.

[John W]

Patrick has made several references in this thread to the provision of "appropriate education". However, just because the therapist has "given appropriate education" doesn't mean it's been received. In the Moseley RCT that I cited up-thread, they used the Survey of Pain Attitudes as a measure of how subjects’ cognitions changed following pain education. In a later study, they demonstrated that patients were able to improve their knowledge of pain neurophysiology based on their scores on a quiz. I don't think performance on the quiz however has been measured against a tool that demonstrates what I'm assuming Patrick is calling "appropriate education".

So unless some reliable and valid measure of the patient's change in attitudes about their pain is being used in the clinic, it's only an assumption that the educational component has been learned. As Moseley has said, the educational component "prepares the soil" and is probably not adequate alone to result in meaningful improvements in pain and disability. The question is what then do we plant in that soil?

My sense is that the combination and interaction of the therapist's and patient's expectations is what makes the "planting stage"-i.e. manual and movement interventions- a difficult clinical decision. I also think that it's very hard to rule out the impact of the therapist's motivation, which is often strongly influenced by a physician referral relationship and the need to make a living.

For these reasons, for patients who express a primary complaint of pain, which I've determined is mechanical in origin, I increasingly err on the side of risk-aversion, while giving a nod to the power and influence of culture (over myself and the patient), by utilizing minimal passive/coercive interventions.

[Diane]

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.

If it is reasonable to do this via skin receptors, it is also reasonable to do the same via other receptors that "remind" the brain of movement.

If we are talking manual contact, skin receptors are the most plausible least wrong receptors to discuss.
I don't think we can get our hands on any of the others without taking the risk of hurting people or upregulating their nociceptive or salience-detection/evaluation defense systems, e.g., jerking them around, or jabbing needles into them.

If we are talking movement therapy, then the brain can refer to its interoceptive and proprioceptive feedback from internal receptors.

[advantage1]

One area I struggle with with regards to patient education is the concept of the protective response and pain inhibition. I use various metaphors/analogies to explain pain and central sensitization. However, I don't have any great examples to use to explain descending inhibition and reduced protective response through manual therapy. Any suggestions?

[caro]

Patrick has made several references in this thread to the provision of "appropriate education". However, just because the therapist has "given appropriate education" doesn't mean it's been received. In the Moseley RCT that I cited up-thread, they used the Survey of Pain Attitudes as a measure of how subjects’ cognitions changed following pain education. In a later study, they demonstrated that patients were able to improve their knowledge of pain neurophysiology based on their scores on a quiz. I don't think performance on the quiz however has been measured against a tool that demonstrates what I'm assuming Patrick is calling "appropriate education".

David Butler went back to uni in order to earn a doctorate in education. Being a good teacher is very, very difficult.

In many ways, it's like asking people to do something they aren't at all trained for. Being a good teacher.

But I think we shouldn't stop trying.

[John W]

which is why I am a bit confused that a clinician moving skin is superior to "passively" moving a body part of another person.

I keep hearing people in this conversation conflate efficacy with defensibility. I think that's a mistake.

What do you mean by "superior", wicked?

[Barrett Dorko]

wicked,

Superior is your word, not mine.

I embrace unpredictability with an additional layer of knowledge and a plausible explanation derived from it. I even evoke Jackson Pollock. That makes my explanation more superior, culturally compelling and, perhaps, even more so confusing and overwhelming, but I'm not claiming that my effect is superior by any means.

I chose Simple Contact as the name and method over "passive movement" because when I was with Paris we taught that manipulation and mobilization was to be referred to that way. What I came to do in the 80s was markedly different than that.

It deserved another name.

[John W]

David Butler went back to uni in order to earn a doctorate in education. Being a good teacher is very, very difficult.

In many ways, it's like asking people to do something they aren't at all trained for. Being a good teacher.

I agree, Carol Lynn. However, we have the distinct advantage in our professions of being permitted to teach with our hands- provide kinesthetic "lessons", as it were. Barrett has always maintained that Simple Contact is first and foremost a method of communicating with the patient. Authentic communication is a key ingredient to fostering learning.

[brolan]

In my mid-twenties there was a period of time where I would wake up from a sound sleep in excruciating pain due to a muscle cramp in my calf. I would remember thinking to myself "why is my body doing this to me?"

After a couple of occurrences, I began to start punching my calf when this would happen. I did this out of the dissatisfaction with my feeling of helplessness and the anger of the occurrence itself. The pain from the cramps diminished with the distraction of me hitting my calf.

Eventually, the cramps ceased after about 5 occurrences.

I give this example, perhaps, as another example of ideomotion. It seems to me that the CNS is responding to a physiological irregularity by performing a muscle cramp for resolution. If this is the case, how do we know that the CNS won't put the body in the position of a pain output (temporarily) in order to resolve another issue? Can it be said that all ideomotion is a response from the CNS towards protection and/or resolution?

Furthermore, I think holding steadfast to a mid 19th century definition is precarious. Has not the understanding of pain evolved? Why not the understanding of ideomotion as well? Why does the word 'idea' have to be used? Why can't ideomotion be born out of complex response? 'Idea' seems to be too simple and confined to the cognitive process.


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[gilbert]

Hi Gilbert, are you talking about the doorway isometrics? If you are right and that is an expression of ideomotion (which I doubt), and if that specific phenomenon is very helpful towards long term pain resolution, then why not just teach the pain patient some isometric exercises vs. SC?

Hi Nari, in your opinion all non volitional movement = ideomotion? As I asked before, how do you differentiate ‘ideomotion’ from any other movement that we are not focally aware?

Hi Evan
The doorway isometrics are NOT ideomotion. I just gave that as an example of how ideomotion feels (to me); effortless and surprising movement.

I was wishing you would spend 5 minutes and try to move ideomotorically yourself. It would help you greatly to understand the phenomenon better, at least it made all the difference for me.

[Jo Bowyer]

But if a person is holding another, aren't there 2 ideomotive responses meeting up

In my case, yes. I started working with ideomotion without knowing what it was in the '70s. To start with I just followed the patient, but started having problems with patients undergoing something similar to non epileptiform seizures which worried me. Surprisingly the patients didn't worry about this and said that they felt less pain and much more relaxed in themselves. It worried the heck out of me though and I was much happier when I trained in cranial osteopathy in the mid '80s, as it seemed that the cranial concepts going through my mind as I was handling the patient seemed to modulate the rather dramatic effects produced by previous interactions.
Nowadays I have the anatomy and physiology of the nervous system in mind as I work and still have very few problems with patients flopping about on the treatment table like fish out of water.

I suspected over 20 years ago that my ideomotion was interacting with that of the patient and for a while worked with mirrors around the treatment table to see if this seemed to be the case and I noticed that my hands shifted to control movement that may have been causing me concern as soon as it started, I wasn't suppressing movement, but I was certainly guiding it. Since this discussion started I have been looking more carefully at what happens when I work nowadays.

There is expression of the patients ideomotion, my ideomotion, my deliberate passive movement, skin stretch, neural glide, interspersed with occasional requests to the patient to do something, eg "Now stretch your leg down the table, but stop if it becomes painful or unpleasant". I have never had to give instruction to young children in this way as they are less inhibited.

The one group of patient's with which I try to avoid ideomotion is those with Non Epileptform Attack Disorder as there is far too much going on without me adding to it. I have had some success in cueing down modulation and have one teenager who has managed to get himself back into mainstream school.

I still manipulate, usually with long lever techniques and very rarely with HVLAT. Imo the skin stretch induced by the positioning induces relaxation and the patient's ideomotion against my stabilisation completes the manouever, joints may or may not cavitate but they will do so without positioning and well away from my hands if the patient relaxes sufficiently.

I am sufficiently squeamish about necks to refuse to use HVLAT which will probably prove to be irrational when Roger Kerry's paper is published. As it is I use head thrust as part of the Vestibular exam two or three times a day, but that seems different somehow.

http://www.youtube.com/watch?v=8zgzZGrIyh8

http://www.youtube.com/watch?v=Wh2ojfgbC3I