Another reason therapists don't know

[Barrett Dorko]

So, where are we? The following are my current conclusions regarding this wonderfully long conversation:

1) I have made no claims of "success" or even effectiveness in the patient's response to their active movement, but I've heard thousands describe improvement in several dimensions and, though these findings are often hard if not impossible to measure, I cannot ignore them.

2) As Blaise says, "unpacking" learned motion from that which we're born with (instinctive) is extremely difficult. Actually, I think it's impossible. In the end, I'm glad to admit that I cannot distinguish between the two, but I wonder how much of a difference that might make. If I've created a context biased toward correction that's what will, in the main, emerge. I think. Not being perfect (and I mean me), this context isn't always what I'd prefer. My colleagues, not understanding any of this, don't often help.

3) Which motion will help is an issue. I'm driven by the characteristics of correction, which makes sense to me but are purely clinical in nature and, as far as I know, unverifiable. Perhaps some ways of measuring people in a reliable and valid way are available. The complexity problem remains. It's not going away.

4) Locus of control has been discussed. I'm with Diane and Bas on this. The speed with which "passive" movement has been introduced, adding to the control a patient might exert. I find that relevant.

5) Simple Contact as an mentally-driven approach and method of handling make sense to me. Proposing that they are a valid way of treating the patient with a complaint of pain because they emphasize any human's tendency to correct simply follows Wall's observation of resolution being instinctive. How did he arrive at this thinking? I don't know. Maybe someone can find out.

Is there more?

[PatrickL]

Why didn't you qualify passive movement with "speed" 700 posts ago, or in your first post?

It didn't occur to me that that parameter was really the basis of my position. Thank you for highlighting that for me.

When passive movement is
Quote:
slow enough that the critter brain of a prepared patient has time to make a representation of the passive movement done unto it by the outside world, it should/will be able to interact/defend its organism/do its job of protection/be stimulated/learn something perhaps. Like how to let go of isometric striate muscle output.
...it is not any longer "coercive" in any meaningful way, such as being forced to do anything against its will.

Why? because, critter brain plays along, doesn't feel a threat, doesn't mount defense.

I agree.

How well can I teach a patient to translate passively applied motion compared to self-generated ideomotion?

For the purpose of self management and /or home exercises? If there is a within session improvement in symptoms/movement (eg retest AROM), isn't that improvement best interpreted as the result, at least in part, of a shift away from defensive motor output regardless of whether the treatment utilized light touch or passive movement?

I think you could use the same advice for self management regardless of whether the manual treatment involved passive movement or light touch

[Diane]

Thank you.
We must never forget the power of temporal summation in the nervous system.
Which is how we can get away with doing (almost) nothing.

[Evanthis Raftopoulos]

What do YOU think is happening when Barrett puts his hands on someone and movement emerges, and other changes accompany the movement? Can you spell it out, since you don't like the explanations that have been offered?

Movement happens during SC, but movement also happens all the time. The context is therapy which affects how the patient perceives/ values the movement (sensitive to the narrative attached to it), however and in the context of pain resolution, the quality and significance of the movement itself is unknown. IMO it might not be different at all than the movement the patient had already been expressing to the point of seeking help(null hypothesis). So I think that it is possible that any positive outcomes on perception following 'unplanned' movement after the therapist places his/her hands on a patient (according to anecdotes here) might as well be due to the placebo effect, in other words, outcomes related to the story that the mind constructed about movement that was already there. I think it is reasonable to say that what is different is not the movement itself but the context. Does that answer your question?

[Barrett Dorko]

I would say that assigning the effect to placebo alone is short-sighted. It doesn't account for the reality of mechanical deformation as an origin and doesn't explain why I (or any other caregiver including some actually famous ones) even exist. Neither does it explain many, many common methods of making others suffer if they don't behave as we'd prefer.

According to the "explanation" you offer, context is everything and always has been - the rest of the explanation need not be present.

It's too much.

[Evanthis Raftopoulos]

Hi Barrett,

I would say that assigning the effect to placebo alone is short-sighted.

It’s one plausible explanation since unplanned movement happens all the time. The main variable that is different with SC is that it happens in the context of therapy.

It doesn't account for the reality of mechanical deformation as an origin

That does not make it any less plausible.

and doesn't explain why I (or any other caregiver including some actually famous ones) even exist.

Neither does this.

Neither does it explain many, many common methods of making others suffer if they don't behave as we'd prefer.

Or this.

It sounds to me that you are suggesting that we should be making more assumptions instead of less.

According to the "explanation" you offer, context is everything and always has been - the rest of the explanation need not be present.

It's too much.

I fail to see why you think it’s too much, while at the same time you try to make a point that it is not sufficient. I find your points somewhat contradictory, or perhaps I'm missing something.

[Evanthis Raftopoulos]

About the locus of control arguments,

One could also argue that all it takes to affect locus of control negatively (the extend being unknown) is an intervention that feels good and helpful towards resolution while it requires the presence of a therapist.

Following the above reasoning one could continue arguing that if you are doing any form of manual therapy then you can’t have it both ways. You either claim that what you do feels helpful to the patient towards resolution, or you claim that what you do doesn’t feel that great and thus it does not affect the patient's locus of control.

Do you see any issues with these arguments?

[Evanthis Raftopoulos]

About 'coercion' and speed of manual intervention, I think it becomes very difficult to make a point if

1. the intervention is safe in the context of tissue injury
2. there is consent for the intervention to happen
3. both therapist and patient think the intervention is optimal for addressing some aspect of the pain problem, and there is also support from the literature

That does not mean that we cannot argue about it. As Mark said before in a different context it becomes more debatable.

About #3, we all define optimality differently, that is partially why we disagree on treatment/movement parameters.

[Bas Asselbergs]

Evanthis,

Following the above reasoning one could continue arguing that if you are doing any form of manual therapy then you can’t have it both ways. You either claim that what you do feels helpful to the patient towards resolution, or you either claim that what you do doesn’t feel that great and thus it does not affect the patient's locus of control.

Patrick:

I think you could use the same advice for self management regardless of whether the manual treatment involved passive movement or light touch

With SC, I do not DO anything other than land my hands lightly on.
When I move a patient passively, I must grasp the limb or head, I must add direction, I decide speed, all based on MY intention.

And you two appear to say that this is exactly the same as far as locus of control is concerned??

I can speak from personal experience that when someone moves my arm, it feels wholly different than when my ideomotion does. It should not be difficult to appreciate the difference.

I was surprised by those remarks.

[nari]

Bas,

Exactly.

What has been one of many issues in this thread is that PTs might prefer passively moving someone, taking the locus of control entirely away from the patient's sense of integrity, however warped that sense may be.

The patient may already be feeling a loss of control over their life and then the therapist enhances that loss. The only exception I can think of is in the case of a very submissive and fragile patient (and we have all had them) passive movement might help.

Restoring a patient's ego and confidence in themselves is essential, in my mind.
Patrick, you have not, it seems, explained why you have passive movement in your personal curriculum......

Nari.

[Barrett Dorko]

Evanthis says:

...unplanned movement happens all the time. The main variable that is different with SC is that it happens in the context of therapy.

Haven't you noticed that most people move in a way that resolves painful problems in the absence of what we create as a therapeutic context?

[Evanthis Raftopoulos]

With SC, I do not DO anything other than land my hands lightly on.
When I move a patient passively, I must grasp the limb or head, I must add direction, I decide speed, all based on MY intention.

And you two appear to say that this is exactly the same as far as locus of control is concerned??

Hi Bas, I have not argued that “this is exactly the same” in the context of locus of control. I said that it is reasonable for one to argue that if an intervention feels good and helpful towards resolution while it necessitates the presence of a therapist, then it affects locus of control negatively. I’m not suggesting that the loss of locus of control is perfectly equal amongst approaches, however, I don’t think that there is a linear relationship between locus of control and speed of movement or any other very specific variable/parameter. The patient-therapist dynamics are much more complex than that in my opinion.

My question to you, why do you feel the need to place your hands on the patient? I fail to see the point. Barrett mentioned that it enhances expectation and self awareness, but this can be argued for any hands on approach. What is it about gentle touch that makes a difference in your opinion? Thank you for your input.

[Evanthis Raftopoulos]

Haven't you noticed that most people move in a way that resolves painful problems in the absence of what we create as a therapeutic context?

Hi Barrett, of course, as I said, unplanned movement is already being expressed by the patient prior seeking any help. The main variable that is different is the context of therapy, which includes gentle touch and a narrative attached to it.

[Evanthis Raftopoulos]

What has been one of many issues in this thread is that PTs might prefer passively moving someone, taking the locus of control entirely away from the patient's sense of integrity, however warped that sense may be.

Who are these evil PTs?! I personally support active/self management approaches and minimum passive interventions, but as mentioned earlier this depends on patient/presentation. When I do practice passive interventions, the goal is usually 1) to assist with movement when there is an identifiable (by patient and therapist) lack of movement, (pain may or may not reduce) or 2) to offer to the patient some form of temporary relief (assuming the pt responds positively based on hx and physical exam).

[Barrett Dorko]

Evanthis asks:

Who are these evil PTs?

Well, all around me. Maybe they're not around you.

I'd say you need to get out more though that doesn't sound very nice.

Still, you need to get out more.

I have the sense that we practice similarly, but we sure don't reason in the same way.

Still waiting for your premise and method revealed somewhere. I can't find it.