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  • I don't know about you guys but the term indefensible seems a little hard for me to understand. Perhaps I missed this somewhere in earlier parts of the thread an actual operational definition. However, without a discussion of context it seems very difficult for me to fully come to terms with what this term means.

    For example, in the context of working with a patient that has expressed that she feels care when she gets a heat pack and electrical stimulation am I to deny her these things, and make her not feel cared for, despite the fact I think the overall evidence for such treatments is rubbish? Does her feeling cared for translate into a teaching moment later in the session because now after feeling cared for she is more receptive to my messages about pain education? I think this point could be argued either way (helpful or hurtful). I don't for one think it is a black or white issue and line I try to walk with my patients.

    Or lets change situations. I am now confronted with a patient in agony due to a degloving injury to her thigh, a complex leg fracture with an IM rod placed distally through her patellar tendon. She is 3 weeks post op, 3.5 weeks since the injury. She has been protective of moving her knee due to what I perceive is a bad combo of being affectively sensitive to the gruff communication of ortho types, prolonged stress response, no being given any kind of forecast (prediciton) for the future outcome of her knee, limited insight into the magnitude of her trauma and what rehab looks like, poor coordination of outpatient rehab services prior to her first visit with me. Now my window to help facilitate knee ROM is limited. Her knee is at 40 degrees s/p massive trauma and we are rounding 4 weeks here. I can't touch her without her crying. IMO, I must take her from acute sensitivity and get her ramped up to be able to put significant amounts of force into her knee within a short period of time or risk her being exposed to more trauma (emotional from people telling her she is not doing good enough, and physical in the form of future manipulations).

    I don't want to get into the nitty gritty details of these case scenarios but it seems like the term indefensible seems to carry the notion that what should be done in each case is clear. In both of these cases I am still vexed as to what the best act actually is. I know I made some decisions that by some strict definition may be indefensible. Who knows, maybe not, but in terms of a theoretical discussion that is divorced from a discussion of actual patient care I find the term indefensible not tenable.
    --------------------------------------------------------------
    Body is imbued with mind, and mind is embodied.

    Comment


    • 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.
      Gilbert, I have no idea what you are asking me to do. How does one move ‘ideomotorically”? Is me dancing ideomotor activity in your opinion? how about playing the guitar, or writing an essay?
      -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
      The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

      Comment


      • Hi Evan, that's why I tried earlier up the thread to explain exactly what worked for me. Try this:
        -stand still
        -let your arm hang down relaxed
        -wait
        (if your arm starts moving, don't stop it)
        ...there you go.

        Comment


        • gilbert,

          Exactly. :thumbs_up

          Nari

          Comment


          • Eric, my use of the term indefensible applies to the reasoning that underpins the choice to go ahead with a particular technique, intervention. I think there are clear examples of indefensible reasoning leading to the "indefensible" application of interventions/techniques. I've been trying to argue that with defensible reasoning, "indefensible" interventions/techniques are no less defensible than DNM and sc (which are implicitly held up as the most defensible methods in manual therapy... Informed by the most advance understanding of the depth and breadth of available research).

            I think this point could be argued either way (helpful or hurtful)
            I agree. I get frustrated with the responses from Diane, Barrett, and john because the responses are always framed in a manner that emphasizes the "helpful" aspects of their reasoning/methods, and the "hurtful" aspects of any alternative methods informed by the same reasoning. This is in spite of the fact that neither John or Diane exclusively adhere to the arguments they present here. John tries to "minimize" his use of passive techniques... Why use any of these techniques if they are indefensible?Diane assures me that we only need to engage the skin and that we can't get our hands on any deeper receptors, but she is happy to use her whole body weight on occasions in an attempt to get her hands on deep nerve trunks. I see a gap between what is argued for and what is actually done practically.

            I think that an understanding of the research available to us, provides scope for a broader range of defensible methods than john, Barrett and Diane are willing to concede (in this thread and others I've been involved in). I have no idea why.

            It feels like arguing politics, like trying to reason someone out of an ideology. Probably futile.

            Comment


            • Originally posted by gilbert View Post
              Hi Evan, that's why I tried earlier up the thread to explain exactly what worked for me. Try this:
              -stand still
              -let your arm hang down relaxed
              -wait
              (if your arm starts moving, don't stop it)
              ...there you go.
              Gilbert, I don’t see how this represent the ideomotor effect.
              1, What is the idea (or mental representation) that causes the movement?
              2. we are aware of the movement as it occurs, are we not?
              -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
              The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

              Comment


              • Originally posted by Evanthis Raftopoulos View Post
                Gilbert, I don’t see how this represent the ideomotor effect.
                1, What is the idea (or mental representation) that causes the movement?
                2. we are aware of the movement as it occurs, are we not?

                1. Any. Subliminal or otherwise have a look at people watching sport, or the referee/judges.
                2. Not unless you decide to be aware.
                Last edited by Jo Bowyer; 17-05-2014, 04:09 PM. Reason: spelling
                Jo Bowyer
                Chartered Physiotherapist Registered Osteopath.
                "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

                Comment


                • Originally posted by Evanthis Raftopoulos View Post
                  Gilbert, I don’t see how this represent the ideomotor effect.
                  1, What is the idea (or mental representation) that causes the movement?
                  2. we are aware of the movement as it occurs, are we not?
                  I have no clue what the idea is, I guess it is in the subconscious? All I know is movement occurs without being planned.

                  I'm aware of the movement when it happens, but I am are not volitionally moving, and it feels strange like it's moving "by itself".

                  Comment


                  • Jo,
                    1. it seems that you are arguing that any movement can be considered as ideomotion as long as we are not focusing on the movement. If yes, then I disagree.
                    2. ideomotion as originaly defined implies that there is no capacity for becoming aware of the movement that occurs as a result of an idea/mental representation. If we are aware of the movement then it's pretty much not ideomotion

                    Gilbert, it seems that you are arguing that any movement that occurs without being planned = ideomotion?
                    -Evan. The postings on this site are my own and do not represent the views or policies of my employer or APTA.
                    The reason why an intellectual community is necessary is that it offers the only hope of grasping the whole. -Robert Maynard Hutchins.

                    Comment


                    • 2. ideomotion as originaly defined implies that there is no capacity for becoming aware of the movement that occurs as a result of an idea/mental representation. If we are aware of the movement then it's pretty much not ideomotion.
                      Dunno about this single definition for ideomotion as above.

                      1) There may be movement that is not eminently visible but sensed.

                      2) There can be wide ranging movement of which one is very aware of but there is little or no volitional control.

                      3) There may be no movement at all - just the characteristics of correction which have been stated very often here.

                      I have experienced all three at various stages for some years, starting from doing nothing.

                      Nari

                      Comment


                      • http://www.medilexicon.com/medicaldi...ry.php?t=43375

                        http://randi.org/encyclopedia/ideomotor%20effect.html
                        Jo Bowyer
                        Chartered Physiotherapist Registered Osteopath.
                        "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

                        Comment


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

                          What do you mean by "superior", wicked?
                          John, my message has been consistent... The degree to which a given intervention is defensible, is contingent upon the reasoning used by the PT in arriving at a decision to use a given intervention/method. To this end, I argue that passively applied movement (of skin or deeper structures) is as defensible as methods utilizing only light touch or choreographed/conscious movement methods. The reasoning behind the choice to use an intervention determines the "defensibility" of the method.

                          You continue to respond with arguments supporting light touch. It's plainly obvious that you see light touch as "superior" in some way to passive applied movement. Otherwise you wouldn't have rallied against my comments (which haven't argued for the superiority of any given approach). I'd say this is what wicked has picked up on. You stop short of stating light touch generates superior outcomes. So where does the superiority lie? I can only conclude that you think those who don't place light touch at the high end of an imagined spectrum of "defensibility" are simply lacking in understanding.

                          Comment


                          • How does one explain to a patient that they're stuck in a protective stage and that this has led to their persistent pain? Also, how do we educate the patient on how our manual therapy techniques could cause descending inhibition and lead to a resolution of pain? I know I've botched this explanation a few times with patients based on their blank stares.
                            Rob Willcott Physiotherapist

                            Comment


                            • Meet them where they are, which is often easier said than done and stay with them while they find Wally/Waldo and all the bits of kit he has lost, you may run out of time, they might decide that your approach is not for them.

                              Yesterday evening I understood something about the nature of the changes involved in achilles tendinopathy thanks to Sam Singh Consultant Foot and Ankle Surgeon (Guy's and St Thomas') it's only taken thirty seven years to grok but I am a slow learner.

                              Grok /ˈɡrɒk/ is a word coined by Robert A. Heinlein for his 1961 science-fiction novel, Stranger in a Strange Land, where it is defined as follows:

                              Grok means to understand so thoroughly that the observer becomes a part of the observed—to merge, blend, intermarry, lose identity in group experience. It means almost everything that we mean by religion, philosophy, and science—and it means as little to us (because of our Earthling assumptions) as color means to a blind man.

                              Also, how do we educate the patient on how our manual therapy techniques could cause descending inhibition and lead to a resolution of pain?
                              Put your hands on and show them.
                              Last edited by Jo Bowyer; 16-05-2014, 03:40 PM. Reason: further thoughts
                              Jo Bowyer
                              Chartered Physiotherapist Registered Osteopath.
                              "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi

                              Comment


                              • I can only conclude that you think those who don't place light touch at the high end of an imagined spectrum of "defensibility" are simply lacking in understanding.
                                Did I "imagine" that there is a theory of primate social grooming? Did I "imagine" the neurophysiology of skin mechanoreceptors and the skin as a social organ? Did I "imagine" the compelling body of epidemiological research on the relationship between locus of control and delayed recovery from injury?

                                Patrick, I think which interventions one ultimately chooses does come down to tolerance of risk-aversion, as you have stated before. I tend to be more wary and skeptical of the medicalized nature of our health care systems writ large as well as of my own motivations to have a financially successful practice. However, I practice in an academic, faculty practice setting that is somewhat buffered from the realities of private practice. I sympathize with and greatly respect those of you who are exerting the herculean effort to make an honest living in this environment.
                                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

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