Another reason therapists don't know

[PatrickL]

note: the education of PTs themselves is a different story... i think it is very important that PTs learn to philosophize about the culture and its role in pain at the population level, and how that should influence their treatment at the single patient level.

[Matthew Danziger]

If you'll permit my thinking aloud (in text?) there are some things I've been mulling over.

I don't stand and stretch in the middle of a movie even when it feels like the right thing to do for my comfort. I'm tempted to say that this desire to move is instinctive despite my awareness, but I'm not sure I would say that my actions are culturally suppressed as much as they are contextually suppressed. It is perfectly acceptable for me to explore all sorts of movement after a long movie. Yes, culture absolutely provides broader context and there is no getting around that, but I can still shift in my seat, slump, and fidget. Yet standing and stretching might be the thing that allows me to explore positions of comfort or just get me moving in different ways. My understanding of Simple Contact is that it (in similar terms) sets out to create the context in which someone feels the movie is over and it's okay to stand and stretch.

Providing the context for novel exploratory movements makes a lot of sense to me, though I certainly don't think that SC is the only way to do this. Perhaps what appeals to me about the use of SC is that (at least in principle) it allows the receiver to explore while the provider follows. Might that add something of value to the therapeutic alliance? Maybe, I don't know.

I've tremendously enjoyed reading this thread and I think everyone involved deserves a big hearty thank you.

[Bas Asselbergs]

WS, I think we can follow someone's ideomotion manually. Why does it not seem possible?

Matthew, what else is culture but context?
I like your mix of awareness with unplanned/instinctive motion - I think that is exactly where I would place ideomotion. Aware of what is happening, but NOT planning the actual motor patterns.
This fits the dowser example: aware of what he is doing, but not preplanning what the motion is going to be (now, there are dowsers who are just scammers....)

[Barrett Dorko]

Evanthis asks:

...what is the specific phenomenon that unplanned movement explains?

Decreased blood flow to the nervous tissue? Impending decrease to the point of pain's output?

Too simple?

Like Bas, I don't know what would be hard about following.

When asked for a more appropriate name for this unplanned and instinctive motion, I thought of several but they all had various forms of my name in them.

I really don't want to go that way.

Anyway, why not say that this movement is within the realm of ideomotion? It's designed to represent what I've suggested. Though instinctive in nature and inherent to life, we haven't explored the possibilities of its being catalyzed until recently. It appears context is important and I've written about that endlessly, here for instance.

We seem to be intensely discussing two things: The name we might use for this movement and the fact some feel that some of us feel it is superior.

As to the first, the movement is still instinctive and has been noticed by those observant in a certain way. I don't think that another name is necessary and I need to clarify in my presentation that I'm talking about catalyzing it as an addition to, well, you know.

The second? I'm still waiting for a stated premise.

[PatrickL]

The second? I'm still waiting for a stated premise.

Seriously? I've written the following 3 times in this thread already

The premise is that the patient is stuck in protection and needs some help to get to resolution. The method is the provision of novel and non threatening input. I think that's the best we can state in support of any manual therapy (non coercive, passive or active).

Everything else is supposition, I think.

[John W]

Ongoing lamenting of the current state of affairs predisposes one to a polarized view of what is defensible practice and what is not i.e. light/non coercive touch is defensible, any other touch is not is not.

This sounds like psychoanalysis to me, or at best an opinion. What is the opinion based on, Patrick? I think your point is arguable on the basis of relevance, but asserting that complaining about how the culture "predisposes one to a polarized view" of anything is pure conjecture. At what point does the lamenting become "ongoing"?

This is interesting. Neither is there for DNM.

Nathan,
I was referring to Patrick's suggestion that passively moving a patient is a form of movement guiding aimed at exploring novel movement, which I don't disagree with. Obviously, when you perform a thrust technique any guiding and exploring ends at the moment you apply the movement over which they have no control. Isn't that the definition of a high, velocity thrust?

If you think that DNM does not include some guiding and exploring of novel movement, then I don't think you understand fully the rationale and physiological underpinnings of this technique.

[PatrickL]

This sounds like psychoanalysis to me, or at best an opinion. What is the opinion based on, Patrick? I think your point is arguable on the basis of relevance, but asserting that complaining about how the culture "predisposes one to a polarized view" of anything is pure conjecture. At what point does the lamenting become "ongoing"?

My comment needs clarifying and wasn't written clearly, sorry.

The lamenting has been ongoing for as long as ss has been a live site, as far as I can tell from my reading. It's more than just the lamenting that leads to the polarized view of what is defensible and what is not. It's the daily meeting of like minded PTs, the regular mutual confirming of a shared interpretation of the relevant science. Its a gradual progressing and reinforcing of certainty with regards to how the relevant science is best interpreted.

Barrett once wrote a thread about selling the neuroscience message to the PT world (there's been more than 1, i know), in which he described the need to get PTs to transition from

"Huh that's interesting"... To... "That's compelling"... To... "That's obvious".

My concern is that the persistence with which you continue to resist the notion that there is no way to differentiate the "defensibility" of coercive touch from non coercive touch, reflects the fact that you have arrived at the point where the idea that light/non coercive touch is most defensible has progressed beyond "interesting" and "compelling" to "obvious".

I think that is a mistake.

[Diane]

This is interesting. Neither is there for DNM.

Nathan,
I was referring to Patrick's suggestion that passively moving a patient is a form of movement guiding aimed at exploring novel movement, which I don't disagree with. Obviously, when you perform a thrust technique any guiding and exploring ends at the moment you apply the movement over which they have no control. Isn't that the definition of a high, velocity thrust?

If you think that DNM does not include some guiding and exploring of novel movement, then I don't think you understand fully the rationale and physiological underpinnings of this technique.

Both Patrick and Nathan have been to a DNM class.
While looking for "movement" isn't part of DNM itself, movement is certainly part of treatment, before and after a bit of DNM. It's a lot of the way one finds one's way along, during a session. Maybe they forgot that part.

Movement after is the surprising part, usually bigger and effortless, so that characteristic of correction we have got covered..

While doing DNM, the big clue is softening.

Warming isn't consistent for me - sometimes there is cooling. Sometimes there is nothing thermal at all. So I don't worry about that. I try to find out if someone is experiencing yes-ciception of some kind however.

I don't lament about the world while in a treatment session.
I do here however, freely... Thought that was what was meant.

[Barrett Dorko]

That someone moves differently in another's hands that aren't mine is perfectly possible, though since the motion is constantly changing I'm not sure how you would determine it. The characteristics of correction would be hard to explain if the movement weren't corrective though. Maybe they don't actually exist. I keep thinking about that.

Perhaps novelty is more important than I had previously thought and I don't emphasize it enough. I wrote a Sunday series about it though. It lasted 5 weeks over two years ago and begins here. Put "Gallagher" in Soma Simple's search engine.

No doubt novelty plays a large part in my thinking, but that begins with the fact I actually seem to know about stuff, will not ask for painful effort, tie my tie in a certain way and on and on.

Patrick, I'm sorry I seem to have skipped or conveniently forgotten your premise. Isn't there sufficient evidence to expand upon it without diving into what you call "supposition"?

That an instinct to move correctively exists is obvious to me. Perhaps not to others. But I want to ask them how they explain the methods used to punish others. Is that fair to ask?

[John W]

Patrick,
Compelling evidence for an intervention requires RCTs. We don't have that level of evidence for either SC or DNM; therefore, they do not meet that high bar. If you have interpreted my promotion of less coercive methods of treatment as an argument that PTs must utilize them because they are based on "compelling" evidence, then I think you've misinterpreted my position.

I agree with you that "passive" handling can be explorational and novel (although I would exclude thrust/HVLA); however, it comes at a risk of creating exteroceptive nociception and it may promote passive coping strategies. I agree that the explanatory narrative that is provided along with the intervention can ameliorate the chance of the latter, but there's no current clinical tool of which I'm aware that can measure whether your "appropriate education" has been learned. The former is at a level of unpredictability that I am usually not comfortable with.

I choose to err on the side of avoiding using coercive techniques because I am particularly sensitive to the strong influence of the biomedical culture surrounding the treatment of pain. I will sometimes use "passive" guiding movements for some patients who have particularly high levels of catastrophizing even after educating them about their pain. (We have valid ways to measure this.) However, in those patients one could argue that their primary complaint of pain is muddled by an irrational fear of moving at all. This seems to occur most often in certain patients who have undergone surgical procedures such as total joint replacements.

Regarding the guiding and exploring of movement with manual techniques: Somatosensory input is inextricably coupled with motor output. I wish I remembered the editorial where Moseley discussed this with some other neuroscientist- I'll try to remember who that was and then search for it again. I'm pretty sure that the moment you place your hands on a patient's skin you will get some activity at least in the pre-motor cortex if not the motor cortex. Isn't the very nature of a non-pathological pain experience characterized by a maladaptive coupling of sensory inputs with motor outputs? Isn't that what Melzack's model shows us? Won't the context created by the culture and the therapist have a huge impact on how that sensory input is interpreted?

Guiding and exploring of movement is not limited to "passively" moving the patient. If that were the case, then why would visualizing the mirror image of moving a limb create activity in the motor cortex of the non-moving limb?

[John W]

I found the article that I was referencing in my last post. The other neuroscientist is none other than Simon Gandevia, who has received quite a bit of attention here for his work on the role of skin in kinesthesia.

[Barrett Dorko]

wicked,

Great post, and, to me, not the least bit boring.

[Josh]

Ideomotion as has been discussed here does seem to misrepresent it's original definition, due to awareness vs unconscious...etc, see all previous posts. Would it be more appropriate to refer to it as instinctual motion? Does it gain us anything by defining it?

[Evanthis Raftopoulos]

i think the proposition is that the unplanned movement reflects movement away from a culturally imposed mechanical deformation of nervous tissue.

But so can planned movement. So this is not exclusive to unplanned movement.

i think it is a defensible idea.

I think it’s a reasonable speculation, but it remains a speculation.

Although for a given presentation of pain, i think that blaming the culture in one sweeping term is not particularly useful. i think one can dig down into the history of the case, and probably find more obvious/specific drivers of the defensive motor output that can be pointed to, thus saving the need to embark upon broad social commentary about the oppressive and lamentable nature of our culture.

Good point. Movement behavior is context sensitive. Culture is part of the context but not everything. It may not be wise to generalize 'culture' as the dominant influence variable to all movement behaviors. Moreover, one could argue that culture enhances and not suppresses movement in many cases.

I don't think patients pay money to hear such unsolicited philosophizing, nor do i think its in our scope of practice to link such broad issues to the patient's pain in such a causal manner.

I think this is debatable and depends on the specific patient-therapist dynamics.

i dont know if ideomotion is the right word for the unplanned movement, based on what evan has been writing.

Thanks for following my arguments Patrick. Much appreciated.


Barrett,

Decreased blood flow to the nervous tissue? Impending decrease to the point of pain's output?

this is not specific to unplanned movement, planned movement can achieve the same. One could also argue than at times (depending on patient/presentation) planned movement (prescribed novel movements by the PT) can achieve this better than any unplanned movement. We can even argue the same for passive movement as far as I know.

When asked for a more appropriate name for this unplanned and instinctive motion,

I’m not sure that the movement we are describing is actually ‘ instinctive’ . unplanned movement can be a learned behavior. If you think otherwise then Simple Contact becomes even more difficult to defend in my opinion.

[Mason]

What would stop self-corrective/ideomotor activity to relieve anoxia from occurring during sleep? I don't think the culture could suppress this.

During NREM sleep, when a person has no conscious awareness of the external environment, I would think movement that relieves mechanical deformation is freely expressed.