Another reason therapists don't know

[zendogg]

Patrick,

Thank you for pursuing this and sticking to your guns. I completely agree with your last few posts as you have summarized your position. I will add one thing to mix and that is J,D, and B point out that light touch has presumably much less risk of evoking nociception that could foul up an opportunity for downregulation.
Things do get muddled when the inconsistency of deeper pressure or even strain/counter strain (passive movement) is applied by Diane or others.

I restate my early point: our physical and verbal contact as PTs , being informed by neuroscience, pain science, and more has the ability to diffuse a neurotag such that protective behaviors can be unwound. The actual physical contribution toward that end provided by our touching or moving a patient is at this time unknowable.

I suggest again that we are arguing a moot point when we nick pick ideomotion versus other forms of passive or active movements. These all are after the fact. Ie they won't emerge until the neurotag is diffused.

Nathan

[Barrett Dorko]

Nathan,

Am I supposed to be "B"?

[nari]

OK. Light touch, passive movement and coercion.

Exclude light touch. It is not essential or required for ideomotion.
So we have two movements requiring touch and one that does not.

All three are claimed to produce satisfactory results with regard to resolution of pain. No one action (or lack of it) is superior to another (established?) so the choice of one over another probably comes down to personal preference:
The therapist is very involved with two actions, plus education. The third one does not involve any therapist directing the movement, only education and interaction.

I have the feeling the lack of involvement and coercion with the third is what bothers some therapists.

Nari

[John W]

It's plainly obvious that you see light touch as "superior" in some way to passive applied movement.

I've tried to make it clear that I think non-coercive touch and movement are more defensible than using coercive touch or movement for patients with non-pathological pain with a mechanical origin and who report pain as the primary complaint.. So, only in this sense do I make a claim of superiority. I've made no other claims of superiority in terms of outcomes or applicability for any given condition. Some comments in this thread, and many others in the past, assumed that this argument was being made to establish superiority of a method in terms of its effectiveness. wickedslow made a vague comment in this regard, and I took the opportunity to ask for clarification. I'm not sure that I understand his/her response, but I don't think I'll ask for any more clarification. I think I made my point.

I think if we are going to call ourselves science-based, doctoring professionals that it is incumbent upon us to include all of the relevant science to explain what we do with patients. I was fortunate to be an undergraduate biology major who was fascinated by evolutionary theory (yes, they teach evolution at Catholic universities in the U.S. ). My impression is that Diane's repeated references to primate social grooming get overlooked far too often. People don't seem to want to go there for some reason. I can conceive of two possible arguments against this theory within the context of treating pain: Either 1) PSG is irrelevant to providing clinical manual therapy or 2) our forebrains have devised a way to take it to another level that goes beyond stimulating skin receptors, but results in a therapeutic outcome that exceeds mere skin-deep contact. I honestly wrestle with 2), but I'm becoming increasingly convinced as I learn more about the most complex and debilitating chronic pain conditions like CRPS and fibromyalgia that the focus of our treatments should be on maladaptive central processing, not the least of which is whatever the pain experience has done to sap patients of their confidence to recover in a timely way. It's become increasingly difficult for me to reconcile that with performing coercive treatments on patients.

[Diane]

Patrick,

Thank you for pursuing this and sticking to your guns. I completely agree with your last few posts as you have summarized your position. I will add one thing to mix and that is J,D, and B point out that light touch has presumably much less risk of evoking nociception that could foul up an opportunity for downregulation.
Things do get muddled when the inconsistency of deeper pressure or even strain/counter strain (passive movement) is applied by Diane or others.

One has to match what's required to move a nerve against the level of "pain" someone has and not over do anything. That's the trick. Minimalism is superior. Why? Because. Just because. Less is more. Weber Fechner and all that.

I restate my early point: our physical and verbal contact as PTs , being informed by neuroscience, pain science, and more has the ability to diffuse a neurotag such that protective behaviors can be unwound.

I prefer the term, "supplanted by a different behaviour the brain (all of it) creates, prefers, and chooses to reinforce."

The actual physical contribution toward that end provided by our touching or moving a patient is at this time unknowable.

Agree! There is no way to know how much force you will "need" until you wade in and find out. Bearing in mind First Law of Human Primate Social Grooming - Do No Nocicepting. The whole point is stress reduction.

[PatrickL]

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?

I agree you have not imagined these things. However from what i can gather i think you and barrett and diane have imagined a spectrum of "defensibility' with regards to the manner in which we handle patients, based on a view that only a particular style of handling can be consistent with the HPSG theory, the physiology of skin, and locus of control issues.

I agree that there exists a threshold above which coercive handling of a patient begins to contradict the HPSG narrative, threaten locus of control, and impede non conscious movement but such inappropriate handling is precluded by the provision of a defensible narrative (a narrative that is inclusive of concepts such as defense vs defect, nervous system sensitivity, withdrawal, protection, resolution, cultural suppression of movement etc etc) to the patient. It just wouldn't make sense to provide a such a narrative, and then go ahead with handling that contradicts the narrative. Perhaps you want to draw a clear line at paasive movement in an attempt to ensure that as the relevant science spreads to the PT community, PTs do not thoughtlessly incorporate an "interactor" narrative without truly changing their "operator" approach. I share that concern, but that concern just isn't grounds for drawing the line of "defensibility" at light touch.

You seem to be convinced that as a general rule, a threshold for "defensibility" is breached as soon as one begins to move a patient passively. I simply disagree. i argue that caring, exploratory passive maneuvering of the patient does not impinge upon locus of control (particularly if treatment is supplemented with choreographed or ideomotoric home exercises), nor does it necessarily contradict HPSG theory or impede a non-conscious shift in motor output from protection to resolution. Nor does it mean that the role of skin mechanoreceptors in the overall interaction are being ignored. Again, i'm not arguing that such passive maneuvering is more defensible than light touch. I'm arguing that if it is the incorporating of the breadth and depth of relevant science that makes a given manual therapy approach defensible, then "defensible" manual therapy can include passive maneuvering of the patient.

In anticipation of a response that we should stick to light/non coercive touch because it is less likely (compared to passive movement) to threaten locus of control, contradict HPSG etc, I'd add that i think there must also exists a lower limit of touch that also threatens locus of control and contradicts the HPSG narrative. Very light touch can easily be interpreted as some sort of intimate/sexual proposition. I think this is worth pointing out because otherwise the assumption is that there is a linear relationship between depth of touch and risk. That would be a mistake, i think. If we include a lower limit, we essentially have a conceptual range of lightness/depth of touch above and below which there is increased risk for loss of locus of control, contradiction of the HPSG narrative, impeding of motor output changes towards correction.

I don't pretend to know where either the lower or upper limits lie for an individual. i doubt they can be generalized for any patient population. Most importantly within the context of this discussion, I don't have any reason to think the upper limit lies at the point at which manually applied forces are sufficient to result in passive maneuvering of the patient. And I haven't seen any argument that reasonably supports the notion that it does.

Minimalism is superior. Why? Because. Just because

Seriously?

[Diane]

yes, seriously. Weber Fechner and all that.

[Jo Bowyer]

I'd add that i think there must also exists a lower limit of touch that also threatens locus of control and contradicts the HPSG narrative. Very light touch can easily be interpreted as some sort of intimate/sexual proposition. I think this is worth pointing out because otherwise the assumption is that there is a linear relationship between depth of touch and risk.

I think that this is a very valid point and it is one of the reasons that I wear a white tunic and keep my treatment sessions short. There are practitioners out there who are of the opinion that the loving parent is an appropriate archetype. Imo this removes the patient's locus of control.

I model myself on the fishing guides who taught me every inch of the river and corrected my technique sometimes with a very light touch on the rod. As I became my own expert, it was less likely that I would have one at my side, we would speak on the 'phone from time to time and they would want to know what I had done and how. The relationship is that of a close one between neophyte employer and expert employee and works with all ages. I find that young children really appreciate being spoken to in this way.

[nari]

Jo, what you have said I think is important to remember. Also the fact that some people find a very light touch quite creepy and react negatively to it.

I'm thinking of Asperger's and those with the condition who find they can't even wear anything touching the wrist or forearm area.

It brings to notice again that people are not all the same and react differently to touch and coercive movement, in fact, any treatment that involves touching.

Nari

[Barrett Dorko]

wicked slow asks:

...are the SC practitioners inducing still points prior to handling?

Not if they were instructed by me, and I use the word "instructed" very loosely.

By making some "still" what do you suppose you're stopping?

[Diane]

More curious to me is that both handling types (SC or PM/FI) have the same issues in that the therapist's organization, intentions, etc are clearly part of their own intent in the handling and in their ideomotor patterns.

Performing FI the information available is dependent not only the person lying there but the person handling them (weber fechner). So I go to lay hands on a person to magnify ideomotor movement, how do I know its not my own ideomotor pattern influencing them.

Which is why manual therapy is actually an interactor model of care, not an operator model of care.

I obviously have an intention and I can only imagine what I don't know and how its influencing my touch. Both types of handling seem to suffer the same complication. if I am practicing to maximize my integration in one form of handling to remain no coercive yet investigative, are the SC practitioners inducing still points prior to handling?

Which is why we (manual therapists) are all still operators when we treat, however interactively we want to treat, no matter how much we might have come to appreciate the importance of touch as communication, not coercion.

I think you have landed on exactly the issues we face as manual therapists. Which is why we need to wrestle with issues like treatment boundaries, amount of force, why it needs to be minimal, why "minimal" doesn't refer to any sort of objective "amount" of force, just to the least amount required in the given set of circumstances, based on whatever ideas are inside your therapist head in relation to how a given patient is presenting, why ideas about pain are so important to understand, why the profession needs to change itself into something less interventionist perhaps, why all this remains so utterly fascinating after lo, all these many years.


I think the more we think about it and do some necessary work on the inside of our own brains, the less "hard" we'll find we need treat other people with manual therapy.

[John W]

perhaps another poor word choice in still, how about aware of your own ideomotion while handling. not stopping, but maybe knowing more clearly what my own movement may be transferring to the person I touch

wicked,
It's not so much your word choice. Rather, it's the grammatical errors and diction/typos that throw me off. I end up having to read a passage like this several times to fill in the gaps in your written expression. I think there's a question in there somewhere, but I see no question mark. It's exhausting.

[Evanthis Raftopoulos]

I am at odds with this problem of ideomotion being seen as the result of an idea that dictates expression.

Hi Nari, how I read this is that you are at odds then with the whole concept of ideomotion.

I have no idea of the idea and I doubt anyone has; if it is an "idea" then we would have no knowledge of it.

If nobody knows what the idea is (including the observer and person moving), and if you suggest that this information is unknowable, then it’s also unknowable when ideomotion actually occurs, especially in the context of physical therapy. We can speculate all we want, but if that's all we are doing then we can't criticize other people in our profession for doing the same thing.

[Evanthis Raftopoulos]

Jo, you provided with two links about ideomotion, but I’m not sure how that answers my questions. Are you arguing that any movement that is not in focal awareness is ideomotion? Are you also arguing that we can become aware of our ideomotion if we choose to do so?

[Barrett Dorko]

Evanthis asks:

Are you also arguing that we can become aware of our ideomotion if we choose to do so?

Why would it become difficult to become aware of it? It's our plan of it that makes it without volition. Not our awareness of it.

Consider the tells in poker.