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Another reason therapists don't know

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  • #61
    Originally posted by nickmPT View Post
    This doesn't add to the discussion, but this reminds me of the movie "Forgetting Sarah Marshall" where Jason Segel is learning to surf, and Paul Rudd keeps telling him to 'do nothing' when he is practicing hopping up to stance on the board. He finally and literally does nothing and just lays prone on the board and Rudd says 'well, you kinda have to do something.'
    Every time I see that scene I can't help but laugh and imagine that is probably pretty close to what some experience when they see me in the clinic. It is not always easy to elucidate the practice of moving more softly/easily, with less effort yet more embodiedly and with more awareness. Personally, I think there is some limitation in my verbal language.
    The unexamined practice is not worth maintaining.


    • #62
      I like people who make up words.

      The microphones in sound studios are sensitive and are sometimes covered with a pop guard, a fuzzy oval device which softens plosive parts of speech. Many years ago Hugh Laurie, after reading through his script said to the sound engineers " I say chaps! There are a lot of bs and ps in this, I think we ought to have a spoffle on".

      My best clinical tutors also made up words and were very creative with the use of vocal range and with movement. They were cheerful, but not insensitive to the mood of the patients.
      Last edited by Jo Bowyer; 01-05-2014, 02:32 PM.
      Jo Bowyer
      Chartered Physiotherapist Registered Osteopath.
      "Out beyond ideas of wrongdoing and rightdoing,there is a field. I'll meet you there." Rumi


      • #63
        Doesn't touching another enhance their awareness of something. Doesn't obviously listening to another alter what they say?

        Why such resistance to this?
        Barrett L. Dorko


        • #64
          Josh asks:

          Why do patients need us to catalyze their ideomotion?
          Barrett L. Dorko


          • #65

            I not sure if I've resisted anything up to this point. I'm simply trying to understand, hence my questions and confusion.
            "The views expressed here are my own and do not reflect the views of my employer."


            • #66

              I don't think you have resisted touching your patients but handling them in a fashion that promotes permission and not direction is something we haven't yet sorted out. You seem not to get this unconscious thing or the fact that corrective movement is sometimes painful briefly. I don't know what else I can say about that.

              Others have wondered why we touch at all. I've said repeatedly it is not necessary, but that doesn't mean it isn't a good idea.

              Many, many therapists tell me that they have a desire poke, prod and passively mobilize any patient they place their hands upon so that "the patient knows I'm doing something." Apparently, they think their patients are like clay. Apparently, patients not only agree but expect to be molded by someone who imagines they "know what they're doing."

              People aren't moldable and, commonly, "therapists" have NO idea what they're doing.
              Last edited by Barrett Dorko; 01-05-2014, 01:30 PM.
              Barrett L. Dorko


              • #67
                For me, this is a study that led me to understand the bodies ability to self-correct:


                This is evidence that the body changes its motor patterns following education and with reduction of threat.
                Rob Willcott Physiotherapist


                • #68
                  How does a study on pain ed and reduced brain activity relate to ideomotion and SC? Is SC's only benefit one of threat reduction?

                  Maybe I'm missing something, but if that's all this is, I won't ask anymore questions.


                  • #69
                    Josh, I'm having difficulty figuring out what you're asking. Maybe someone else can.

                    Let me ask (Socratically): Given that mechanical deformation beyond our tolerance is unquestionably an origin of pain, wouldn't a reduction in that contribute to pain relief? Wouldn't that happen instinctively given the opportunity? Wouldn't that require movement of some sort? Wouldn't threat be reduced once the movement occurred? Wouldn't the culture have something to say about that? Is it likely that bringing attention to cultural influence through story, example and touch is part of therapy?

                    Do you really think that some picture of the brain is going to tell us all we need to know?

                    I've more questions, but that's what I'd like to see discussed. Anyone, of course, can answer.
                    Barrett L. Dorko


                    • #70

                      My intention, I guess, is to describe the therapists I've worked beside during the past 7 years, none of whom ever read anything, as far as I can tell.

                      Not you. Please note I said "commonly."

                      They're well-intentioned, for the most part, but disengaged and Intellectually LAZY.
                      Last edited by Barrett Dorko; 01-05-2014, 03:35 PM.
                      Barrett L. Dorko


                      • #71
                        Barrett, as you know, mechanical deformation is unquestionably an origin of nociception not pain, reduction in that deformation would reduce nociception and maybe pain.

                        I always hear you speak of a method that is defensible, I am asking for your clarification and I get the socrates method of answering questions with more questions.

                        I'm not questioning if ideomotion exists, I'm questioning ones ability to change, elicit, catalyze, anothers ideomotion with touch in a reliable, meanigful fashion in relation to the treatment of pain. Is unleashing ones ideomotion really our goal as a PT?


                        • #72
                          How does a study on (..) reduced brain activity relate to ideomotion and SC? Is SC's only benefit one of threat reduction?
                          Josh, any motor output is affected by altered (increased or decreased) pain related brain activity related to protective physical behaviour. This study shows decreased levels of "alarm" activity. Ideomotion is partially a motor output.

                          And yes, threat perception reduction is what all of our treatments are all about. Healing (with some good advice) takes care of itself - so what else is left?
                          We don't see things as they are, we see things as WE are - Anais Nin

                          I suppose it's easier to believe something than it is to understand it.
                          Cmdr. Chris Hadfield on rise of poor / pseudo science

                          Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                          We don't need a body to feel a body. Ronald Melzack


                          • #73
                            Josh says:

                            I always hear you speak of a method that is defensible, I am asking for your clarification and I get the socrates method of answering questions with more questions.
                            Josh, It doesn't sound as if you've read much of the hundreds of essay I've written in defense of corrective movement for pain relief. I really appreciate your pointing out that I know the difference between nociception and pain. Thank you so much.

                            Let's try this, though I don't like making this long. Luke Rickards is an osteopath in Australia and he wrote this as an introduction to his single system study:

                            Ideomotion can be described as instinctive, automatic expressions directly coupling dominant mental representations to action without intermediary volition (Carpenter, 1852; Spitz, 1997; Dorland, 2003). Ideomotor theory suggests that motor patterns can be automatically and intimately associated with their internal and external sensory effects, and will occur in the absence of any other cognitive representation or efferent motor command (Kunde et al., 2007). Although ideomotion has been commonly associated with non-volitional movements (Spitz, 1997), ideomotor theory also provides a compelling explanation for the generation of goal-oriented voluntary actions (Kunde et al., 2007; Keller et al., 2006). During ideomotor movements the sensory effects, such as the kinaesthetic and interoceptive sensations that may accompany each movement, are directly coupled with the generation of the movement itself (Knoblich & Prinz, 2005). Thus a kinaesthetic representation of a position that may be associated with reduced pain sensation, or stretch of a stiffened tissue, will be automatically coupled to the movement that produces the represented sensation. The pathway from sensory effect representation to movement may also involve feedback from the peripheral sensory apparatus at levels below attention, and this sensory input may facilitate the elaboration of motor patterns at higher levels (Cole, 2004). Alterations in motor output during the movement may be generated by continuing sensory effect representations and may be influenced by both conscious and non-conscious peripheral sensory feedback, thus resulting in the complex movement patterns seen during the intervention (Cole, 2004). Since varying interoceptive sensations may be perceived with even minute alterations in motor output in some instances movements may not be visible, though they will often still be palpable (Spitz, 1997).

                            Chronic spinal pain is commonly associated with reduced or altered movement (Leeuw et al., 2007). Most approaches to spinal pain management incorporate movement of some kind into the treatment strategy, however the factors underlying the observed benefits of movement are unclear and both physical and psychological mechanisms have been proposed (Moseley, 2003; Slade & Keating, 2007; Leeuw et al., 2007). Resistance exercises with the aim of strengthening deconditioned tissue or to address impairments in control and stability are commonly prescribed for chronic pain, however unloaded movement facilitation exercises produce comparable effects (Slade & Keating, 2007). There is accumulating evidence that pain-related fear is a significant factor in reduced or altered movement in chronic pain and challenging these fears in the context of movement is also associated with improved outcomes (Leeuw et al., 2007; Woods & Asmundson, 2007; Moseley, 2003). Evidence from movement exposure in vivo studies examining fear-avoidance behaviours in chronic low back pain have emphasized the importance of practicing a wide variety of movements both during treatment and as home exercise (Leeuw et al., 2007). Although the intervention used in this study may be described as a manual therapy, it is an entirely active approach and mimics several aspects of both unloaded movement facilitation exercises and movement exposure in vivo.

                            I said I didn't understand your question and asked for help. Apparently Bas does so there you go. You don't feel any obligation to answer mine? You don't like or agree with the Socratic method?

                            Additionally Josh asks:

                            Is unleashing ones ideomotion really our goal as a PT?
                            For a long time I've seen pain relief as a reason to understand the complex nature of this phenomenon of the brain's output and how I might help patients and colleagues get through the day. I know it isn't always related to the goals set by other therapists. To many, walking is a goal, standing another and so on. Their patients work on these things and grow closer to or surpass them. Meanwhile, complaints of pain are ignored or left to those who think that chemical manipulation is the main means of relief available.

                            We can know more than that, and if the therapist using movement knows little or nothing about pain's complexity, the patient will often suffer needlessly. This is NOT to say that goals aren't met, just that mine include pain relief via motion. I've learned that many PTs couldn't possibly care less about their patient's sensation of pain. "We know nothing about that" and "It's the patient's fault" are things I've heard countless times.

                            Is my method reliable? Luke's study indicates that, but it's only one. Time and again we've said here that methods for which there is evidence of effectiveness are legion - it is the explanation for their effect that is lacking. Luke's explanation and citations are a step in that direction.

                            Is that meaningful?

                            Anyone care to address that?
                            Barrett L. Dorko


                            • #74
                              Josh, in addition to these last two posts I'd like to add that studying ideomotion in any controlled setting is akin to studying the validity of parachutes as methods against falling to death.

                              These both have in common a very solid application of accepted and known aspects of our world - in one, gravity, experience from falling over smaller distances, fragility of human structure; in the other, naturally occurring self-corrective motion, the most common triggers for nociceptive signalling (chemical and/or mechanical), and human neurophysiology.
                              No controlled studies and neither are really falsifyable.
                              We don't see things as they are, we see things as WE are - Anais Nin

                              I suppose it's easier to believe something than it is to understand it.
                              Cmdr. Chris Hadfield on rise of poor / pseudo science

                              Pain is a conscious correlate of the implicit perception of threat to body tissue - Lorimer Moseley

                              We don't need a body to feel a body. Ronald Melzack


                              • #75
                                Thanks Bas.

                                In fairness to Josh, he's wondering (I guess) how something can be deemed helpful or the "goal" of a physical therapist if it does nothing more than propose it relieves pain.

                                After 28 years in private practice I discovered that the patient's complaints of pain, which seemed to me how I stayed in business for so long, had been virtually ignored by my colleagues and, though the educational requirements for licensure had massively increased, been shunted aside in the PT programs.

                                Now Josh works (I'm presuming here) in a setting where its reduction is confusing, to say the least. Frustrated with no one seeming to know about it or care, even the patients assume it can't be helped with effortless, instinctively emerging movement so chemical manipulation ("Take pain meds in a timely fashion before attending PT") is the only thing they have. PT is for effort, sweat, reaching for goals and enduring pain seems the message now and, taking its lead from the culture, therapists have simply gone right along.

                                Dinosaurs like us, well, you know.

                                I look forward to actually meeting you next week.
                                Barrett L. Dorko