Another reason therapists don't know

[Barrett Dorko]

Nathan,

How is it that "motion is motion"?

Wouldn't a motion that increased mechanical deformation make the patient's output of pain worse?

I have to wonder why I'm even asking that question.

[zendogg]

Yes of course.
But I would make the presumption that most normal people wouldn't attempt to exacerbate their pain.
Is that your answer to the questions I raised?

[Barrett Dorko]

Somehow, I seem not to have made something clear.

Maybe someone else can. I'm worn out.

[Mason]

In your opinion, aren’t we being somewhat deceptive to the patient if we deliver manual therapy with methods/rationals that not only lack evidence, but also plausibility and falsifiability?

I would add that suggesting to a patient that cultural influences are a reason their pain is not resolving and that outside influences easily suppress the mechanisms needed to get out of pain is not without potential harm to the person's self-efficacy.

[Josh]

Cory,
Thanks for your post and I agree with most, especially your outline of your inclination to use manual therapy.

I would disagree with instinctive motion being everything not coerced. I see most of our motion as a learned behavior vs instinctual. When a patient comes to therapy, I see my role as assisting them in learning behavior vs unlocking instinctive movements suppressed by culture.

Do I know which motion will help? Not until the patient tries it and provides feedback, but we usually learn together and figure it out. When they move in a way that reduces pain, I provide feedback, reassurance, and encouragement to do this on their own. To me it increases their ownership of the situation without a story about subconscious ideomotion.

[zendogg]

Somehow, I seem not to have made something clear.

Maybe someone else can. I'm worn out.

Barrett, it is difficult I'm sure to help people who want nothing but to understand and keep asking questions. I'm not a dolt and neither are the people who keep asking questions. The answers thus far aren't clear to me. I'm sorry.

Can you at least answer this, as rudimentary and repetitive as it is, without asking a question in reply: do you claim that with the HANDS-ON application of simple contact (and the context setting) that the movement which emerges IS THAT WHICH REDUCES PAIN OUTPUT?

[PatrickL]

So, my inclination to use manual therapy is based on the assumption that I can do so 1) without being deceptive, without pretending that the effect is something other than non-specific and due to the magic of a needle or a special tissue, etc. and 2) it poses no greater risk than natural course history and 3) the patient can maintain self efficacy so there is no danger of worsening outcome and taking the unacceptable position of being worse than natural course history.

well said. i think we all agree on 1. i think we (john and i in particular) differ on where the upper and lower limits of acceptable risk (with regards to manner of touch and its relationship to locus of control) for 2 should lie. From what i gather, he does not acknowledge, or has not acknowledged in this thread that there exists a lower limit (in terms of lightness of touch) that on the backdrop of treatment context might influence locus of control and hinder the natural course of recovery. It also appears to me that he thinks that the upper limit of acceptable risk lies at the point when a PT starts moving a patient passively. I don't see any reason to think that is the case. And no diane, just to be clear, that does not mean I am an advocate of rape. There probably exists an upper limit of weight/speed/pressure that threatens locus of control even in the presence of a defensible narrative. I still maintain the use of such force/speed/pressure would so obviously contradict a defensible accompanying explanatory narrative, that providing such force/speed would be precluded.

I simply think that there exists scope for the defensible application of a range of patient handling techniques. As long as PTs aren't creating nociception, or actually causing pain, or feeding the patient a bunch of nonsense, i have a high tolerance for the inclusion of "operator" handling of the patient. I don't actually do much of it myself, but I think a tolerance for such handling will better serve my attempts to positively affect the profession. Perhaps a dogged intolerance of such handling better serves diane, john and barrett's attempts to positively affect the profession.

[John W]

Allow me to try a different approach.

Evan deserves an answer to his question that I- perhaps abruptly and unfairly- labeled as "ridiculous" as does Patrick, who continues to make references to the "untestability" of some of the concepts that I and others have been arguing for, including the superior defensibility of a minimalist approach to manual therapy interventions and the idea of self-correction.

First I need to say that I think this discussion is going around in some unproductive circles for one core reason, and that is because we- all of us to some degree- are treating the aporia of pain as a phenomenon that is amenable to a singularly positivist approach to inquiry. I think this is a big mistake, and I'm as guilty as anyone of falling into the trap of trying to defend my positions from this very limited perspective; although, I think if you look through many of the comments that Diane, Nari, Barrett and I have made during this marathon thread, there's an honest and repeated acknowledgment of the inherent uncertainty associated with entering what Quintner and Cohen refer to as "the third space".

For example, when we suggest that the human organism is "self-corrective", it's very easy to dismiss as untrue because the lived pain experience exists within a culture, a family, a workplace, a gender identity, and so on. To the extent that these cultural factors impact (both positively and negatively) the inherent capacity to self-correct (best summarized by Wall's three stages of withdrawal, protection and resolution), it seems inevitable that self-correction is bound to be influenced in some way. Our argument (in item #8 of the Moderators’ Current Consensus on Pain document), of course, is that the cultural influence is resoundingly negative, not the least of which is due to the hyper-medicalization of the person with a pain predicament. Therefore, the conclusion is I think mistakenly drawn that in all practicality, self-correction doesn't exist, and this seems to occur at precisely the moment the person goes from having a pain predicament to seeking professional care to extricate themselves from it. Therefore, Wall's stages now become very well-stated and defensible science, but strangely irrelevant to us once the person experiencing a pain output is removed from the theoretical realm of neurophysiology and placed into their life. But we know that self-correction, on some level, does exist in real life. All of us have experienced fleeting pains that end up being of no consequence other than having entered our awareness in one moment only to disappear the next. We don’t seek care for this, of course, so it’s not a predicament that warrants anything but our own “purely” self-corrective devices. Does this capacity suddenly disappear, however, just because a person becomes a patient?

I want to be clear that I’m not talking about seeking "comfort", which is why I became impatient with Evan's question to Barrett. Barrett used an everyday example of Wall's stages that all of us are familiar with (and also which I think we agree are based in sound science) and then Evan asked whether Barrett thought that all movement that produces "comfort" is ideomotion. But patient’s don’t come to see us to seek comfort, they come for treatment (more commonly they are referred to us by a medical professional) because they have a pain problem. Barrett doesn’t claim to catalyze ideomotion for Tom, Dick or Harriet who is seeking some higher level of comfort; rather, he applies this sound neurophysiological proposition of self-correction within the context of treating a patient who has usually been referred to him with a pain problem. Everything fundamentally changes at the moment that person in pain goes from having a predicament that is driven by pain to a patient seeking care. Does that mean that the physiology of self-correction is no longer valid? What if during one of my fleeting pain moments, I realize that I’ve spent a lot of time at the keyboard, and that I haven’t moved enough- something that I’ve learned from studying the neurophysiology of pain. I can’t stop working on my current project, so I set a timer to take some “microbreaks” that include simply increasing my movement repertoire and maybe some diaphragmatic breathing for a couple of minutes, and sure enough the pain episode passes. Because I learned from a third party this concept of movement poverty potentially leading to ischemia, which is then followed by Wall’s three stages in response to a certain threshold of sensory-discriminative input, does that mean that the action I take precludes the neurophysiological concept of self-correction? I don’t think it does. Rather, it alters the input from one dimension on the left side of the neuromatrix, which allows my self-corrective capacity to emerge and resolution to proceed.

Like everyone else, I’m immersed in the very same culture that is at the root of the pain epidemic. My embodiment within that culture is like a cloud under the influence of temperature gradients and alterations in topography- fractal, unpredictable and subject to the butterfly effect. But that’s not to say that conditions cannot be altered in a reasonable, defensible and effective way that will allow my inherent capacity for self-correction to emerge.

I’ll leave this overly long comment with this. I spent a weekend at a course recently with Adriaan Louw, who is leading the charge in the U.S. for incorporating therapeutic neuroscience education for our patients. I asked him if he had considered going to the grade schools to propose teaching these concepts to young children thinking that doing so could have a significant impact on the current pain epidemic. Not only did he think it was a good idea, he’s already on it! He lamented, though, how difficult it has been to get school systems to approve such a thing. I can only imagine. If this does happen, and Adriaan follows these kids in a longitudinal study over the next 10 years and finds a significant drop in persistent musculoskeletal pain problems, do we conclude that these kids, because they gained a better understanding of pain in grade school, were not self-corrective anymore? I think that would be the wrong conclusion.

[Evanthis Raftopoulos]

Barrett used an everyday example of Wall's stages that all of us are familiar with (and also which I think we agree are based in sound science) and then Evan asked whether Barrett thought that all movement that produces "comfort" is ideomotion. But patient’s don’t come to see us to seek comfort, they come for treatment

John, it was an honest question and a reasonable one following Barrett’s comments on ideomotion and the example with his coworker moving to improve comfort. Diane responded to my question with “And yes, I think that is what Barrett is suggesting. Movement improves comfort.” It sounds to me that you are in disagreement with Diane, and with what Diane thinks that Barrett is suggesting. Barrett didn’t even bother responding.

btw 'treatment' and 'comfort' can coincide in the sufferer's mind when seeking help. Whether we think that it's our responsibility to provide with comfort (and how much of it/what form) or not is a different story.

[BB]

Not sure I'll be able to keep up with the thread as I'd like, now that I've waded in, but will try.

Evan:

With or without evidence we still need to examine the plausibility and falsifiability of the claims.

Excellent point, and I couldn't agree more. Huge Karl Popper fan. To clarify my stance, a claim need not be falsifiable to be useful, it just isn't a scientific argument it is then an explanatory system. In the case of SC or any treatment method, there is falsifiability if the question is posed correctly in relation to its potential effects in resolving pain. Of course, this question has not been adequately studied to have an answer at this point. Regarding plausibility, there is the "end state comfort effect" as one example. Search the term on the tools here if you're not already familiar.

We have to leave the level of consciousness and awareness out, but then we are also changing Carpenter’s definition.

The current research on ideomotion, to my understanding, concern intention. All movement occurs below consciousness, but a movement is considered "ideomotor" when the intention is assigned to ourselves. Lot's of interesting stuff on this as well as ways to play around with it. There is also potential here for falsifiability as there have been identified differences on the neural patterns with an "ideomotor" task.

Skipping ahead a bit, and realize that I obviously am speaking only for myself, at this point I personally find ideomotor, instinctive, and volitional descriptions to be helpful only so far as they get us to the point to realize the importance of self efficacy. I've argued in the past that the potential preference for skin deep manual therapy (as opposed to other kinds) is in its unlikelihood to foster an external locus of control given the predominance of certain expectations and types of thinking. "How can the problem possibly be a bone out of place when you feel better after nothing other than skin deep pressure?" That sort of thing.

When the argument comes down to this being more effective than another type, there is no data of which I am aware that settles the argument. However, I assume (for reasons I discussed before) that self efficacy is better fostered when approached in certain ways. There is evidence that self efficacy is hindered when approached in certain ways.

All that said, I passively move people all the time. I consider it a very useful way to introduce novelty and honestly, I'm often looking for the first point of entry for that so we have a direction in which to run and limit the exposure to any potential "medicalizing" encounter. And that has become increasingly my goal over time.

Also, I believe you mentioned placebo's having specific effects. You can look physiologically and find specific objective measurable effects. But, when we are talking about the health effect of pain, when adequately controlled I stick to the null that manual therapy will always be non-specific in its effect. No one is suffering from a "manual therapy deficit."

zendog:

Is the movement that we FEEL (yet can't see) in our patients that is elicited or magnified by our touch, THE active corrective element that diminishes pain?

My answer: no. Again, I assume that manual therapy is always non-specific effect. My working theory is that, when effective, it is because it fostered self efficacy in a context that was disarming and encouraged a change in narrative consistent with resolution. The movement may have been the vehicle, and the touch may have been the catalyst.

How is this movement (which I will not put a name to) any different from any other movement a patient is currently performing on their own (and yet they remain in pain before seeing us?).

It is only different in as much as it changes the narrative. This is, in my mind, the strength of SC as a method. It is tough to set up and tough to sell, but if and when you do, if is tough for the recipient to find it anything other than a confirmation of their own self efficacy, their own ability to find their way out of their problem (as John spelled out so well below).

Josh:

I would disagree with instinctive motion being everything not coerced. I see most of our motion as a learned behavior vs instinctual.

What motions do we do that are not learned? We differentiate from reflexive motions, like heart beat, blinking etc. Otherwise, in what way can we move that did not undergo some form of learning? Some is basic, some is honed from a lifetime, but all are learned. So, to me, "instinctive motion" other than to differentiate from heart rate, is a like saying water is water.

Patrick:

I hear you. As I mentioned before we work in situations that are not adequately informed by the research and thus require assumptions which should be guided by sound ethical and philosophical stances, which by the way can exist in opposing yet defensible camps, IMO. Just see the progression from Popper to Kuhn, to Lakotos and Feyerbend. I of course favor a certain set, but must also therefore watch out for my confirmation bias.

Night folks.

[Jo Bowyer]

My attempt at answering Zendogg's questions.

Is the movement that we FEEL (yet can't see) in our patients that is elicited or magnified by our touch, THE active corrective element that diminishes pain? I'm not naming this movement because I don't really care what it's called. It is present and I want to know if it is the thing that is diminishing pain.

The patients will sometimes say that "the movement moved me" or "I wasn't breathing, I was breathed"

How is this movement (which I will not put a name to) any different from any other movement a patient is currently performing on their own

It is a dance evolved by the interaction of the patient's critter brain with the practitioner. In the case of those who produce it without a practitioner the dance arises from interaction between the critter brain and the executive areas of the person's brain/brain's person!!?

If we claim this motion associated with simple contact has special capabilities wouldn't those capabilities be attributable to the brain rather than the movement itself?

In the case of what I do, yes.

I can't speak for simple contact as I am not Barrett. I have followed a similar path with regards to ideomotion/whatever this is since the mid '70s, but unlike Barrett have not put myself in the firing line. I'm just "that British physiotherapist who does that thing" and for a while New Yorkers would come over on the concord until the next thing took over.

In my case the special effects, I wouldn't go so far as to call them capabilities, arise as a result of what the patient's brain has done with the initial stimulus. The initial stimulus might be a touch from me or a rephrasing of something they have told me during the case history and on several occasions, my posture/body language, which is usually very relaxed as I have 'heard it all before'.

[PatrickL]

do we conclude that these kids, because they gained a better understanding of pain in grade school, were not self-corrective anymore? I think that would be the wrong conclusion.

John, I still don't think it makes sense to simply state that we are self corrective. If this were the case, the culture, no matter how powerful, would not be able to suppress self correction. Isn't that straight forward? If your hypothetical longitudinal study did result in a reduction in persistent pain problems, wouldn't that be indicative of the inadequacy of inherent corrective mechanisms? Wouldn't it be indicative of a need for intervention in the form of education?

Perhaps ideally we'd revert to a simpler time in history where human communication was less complex, less fettered by social expectations and the like. A time where homeostatic mechanisms that served the purpose of keeping nociception in check could go on unsuppressed. But we don't live in that world. For better or worse we evolved a massive cerebral cortex that led to the establishing of complex, layered societies. I think the chronic pain epidemic reflects just how ineffective these homeostatic mechanisms have become under the shadow of the cerebral cortex, and how irrelevant nociception from mechanical deformation of nervous tissue is relative to other "survival needs" of the modern day human.

If we were self corrective, that portion of the chronic pain epidemic with a mechanical origin wouldn't exist. But it does exist. And changing things requires intervention. Intervention could be as simple as education, or even an empathetic ear lent to the patient.

I think a premise would be better stated as "we have an inherent capacity for self correction". I don't agree that a minimalist approach is the most defensible. I'm not even sure how a minimalist approach is defined, given that those who espouse it admit to using passive movement, leaning with all their body weight and performing maitland like mobs. I think there exists scope for a variety of defensible approaches, so long as they promote self efficacy, don't cause nociception, and don't cause pain for the patient. Perhaps I could argue that a minimalist approach is one that doesn't cause nociception, doesn't cause pain, and doesn't abuse the power that inevitably accompanies the patient's handing over of locus of control.

I understand that when there is a favourable outcome following treatment with only light touch (or no touch), it is a powerful reinforcer of the accompanying narrative. I love it when a treatment sessions falls into place like that. But it's always a gamble. On the flipside, passive movement is a gamble too.

Barrett wrote something a while back that stuck with me. It summarizes my ongoing struggle to be the PT that I need to be to help the patient in front of me. It went something like:

What story does the patient want to hear? What story should the patient hear? What story can I tolerate saying?

[Barrett Dorko]

Patrick says:

I still don't think it makes sense to simply state that we are self corrective. If this were the case, the culture, no matter how powerful, would not be able to suppress self correction.

I've a lot yet to read and digest today, but this statement stood out for me initially.

It seems Patrick and I have a vastly different views of the culture's power.

[PatrickL]

It seems Patrick and I have a vastly different views of the culture's power.

I don't think you can conclude that, given that I included the qualifier "regardless of how powerful the culture is"

[Bas Asselbergs]

Patrick, I listed somewhere on this thread some very common "instructions" that every north american child/teen hears regularly, as well as the folloing:

Random, free, unsuppressed and unchoreographed motion is completely counter-cultural on our continent. I think we can agree on that.
This is the cultural variable that can be assumed to influence most any of us.

Do you disagree that these aspects of culture are sufficient to influence our free, unfettered, physical movement?