Another reason therapists don't know

[Mason]

It would be helpful to this discussion to define "correction". The term is being used to refer to at least two things in this thread, one being the reversal of the effects of mechanical deformation on tissue and another being the resolution of the pain state.

Sensory input from the mechanical deformation of cells is one factor among many that regulates movement. It occurs along side many other physiologic and biochemical pathways triggered by the deformation of cells. I don't think we can attribute a purpose to these actions. They are there, and they probably exist because they helped with survival in the past. The relief of mechanical deformation may be the probable outcome of these actions, but it does not always occur. The large neocortex adds to the complexity of this.

We could interpret the probability of ending up in a "corrected state" to mean generally we are self-corrective, but as others have stated I think saying we have the inherent capacity for self-correction is better. If an intervention is required to undo the effects of mechanical deformation then "self-correction" did not occur and was not present. The first post in this thread stated that self-correction is always there which I think is inaccurate.

[Barrett Dorko]

Mason says:

The first post in this thread stated that self-correction is always there which I think is inaccurate.

Oh.

[Evanthis Raftopoulos]

Hi Gilbert,

Evan, don't you think there is a difference between consciously thinking that something is a threat, vs. the brain making a determination of a threat at a sub-conscious level and outputting pain, as described by Moseley? I do.

Yes. My understanding from studying relational science and systems biology is that we have an internal predictive model (call it Neuromatrix if you like) that evaluates ‘threat’ (Eg. how far from stable states we are) and constructs the pain experience. As I expressed before, there is a relational aspect between mental models that guide thoughts / behaviors and this model.

And likewise I think that when I move volitionally to pick up a book it is different than when I move non-volitionally (ideomotorically).

You are saying here that ideomotion = non volitional movement. This seems to be inaccurate according to the most recent discussion here. Have you read any of Cory’s posts or his reference? Do you disagree that ideomotion is associated with an idea/thought and thus is better described as volitional vs. non volitional movement? If you feel confused then case in point, these terms are confusing and have little to no explanatory value in the context of physical therapy practice (just my opinion from this whole discussion).

BTW did you ever try what I suggested earlier in this thread? If so how was it?

I still think that we cannot elicit ‘non volitional' movement. The terms are contradictory. The exercise you keep asking me to do has an intention. The intention is to go in a quiet room, relax, and move in random directions. The movement behavior is created intentionally by thoughts/ideas. Even if I'm not instructed to move in random directions, the idea is there given the context of the discussion. If you give me no instructions, or slightly different instructions, then the movement behavior will be different. Do you disagree?

[Evanthis Raftopoulos]

Evan, if you did try to catalyse a (adjective of choice) movement or sensations of warmth etc, as gilbert and I and others have suggested, you would soon understand better how your statement of

Quote:
I don't see any explanatory value for utilizing terms like volitional, non volitional, and ideomotion.

would fall apart at the seams, although it may be difficult to name such terms appropriately.

Hi Nari, I disagree for reasons already stated. btw if I go for a run don't I catalyze movement or sensations of warmth? Is there any movement/exercise that does not achieve that?

[Evanthis Raftopoulos]

Hi John, if you think that these terms (volitional, non volitional, ideomotion) are useful to you and your patients, and if you are confident that you can communicate them accurately, then you should continue using them. I don't feel the same way obviously, at least not at this point in time and given the arguments presented here. And I have no doubt that the "trapped emotions in the fascia" is nonsense.

[John W]

Evan,
I don't talk to patients about "volitional" and "non-volitional"- probably because it's too confusing for many of the reasons you've stated in such abundant detail. But I do talk to them about breathing (excitomotor), startle responses (sensorimotor) and the subtle positional shifts and adjustments that they make even though they are not necessarily or even typically aware that they are making them (ideomotor). I don't use the word "ideomotor" with patients- at least I don't ever recall using it.

As I said, classifying movement categories in this way seems to help patients understand how inherent movement is to living and how not moving enough- or more accurately without enough variety- can lead to persistent pain problems. When you educate them about pain, elevated nervous system sensitivity and the associated "guarding response", it makes sense to them why performing subtle, pain free and novel movements will help them resolve their pain problem. It's also been my experience that patients are relieved when they find out that I'm not going to make them do exercises that hurt because they are too weak or too tight in some muscle or other connective tissue.

I think this narrative also helps them achieve a higher level of awareness and control over their own bodies. It improves their sense of embodied self, and ultimately their self-confidence. It's empowering. That's critical.

Given our currently limited knowledge of such heady topics as consciousness, volition and goal-directed behavior, to name a few topics that have come up in this thread, I think this narrative possesses a reasonably defensible foundation over a broad swath of the relevant science.

Perhaps you will one day start a thread where you describe how you explain what you do to your patients. I'd be interested to hear about it.

[BobV]

I think BobV mentioned recently something important about non-specific effects . If for example the effects we are are trying to deliver is placebo-related analgesia then the effect becomes specific. Non specific implies that we are trying to deliver something specific, and on top of that some non specific effects occur. Bob if you are reading this correct me if this has not been your point.

You are right, specific means it is a effect targeted on a specific outcome. Here's my Original statement you are referring to

http://www.somasimple.com/forums/sho...291#post179291

Bob

[BobV]

Oops, posted it twice by accident!

Bob

[marcel]

Exactly. Becoming a patient is a CHOICE. Unfortunately, within the current perverse culture of medicalization, it often turns out to be an unwise one.

John, do you have any references for that?

PS the question doesn't mean I disagree, it is an interesting point.

[Barrett Dorko]

John says to Evan:

Perhaps you will one day start a thread where you describe how you explain what you do to your patients. I'd be interested to hear about it.

I'd be interested as well.

[John W]

Marcel,
It was unwise of me to phrase it the way I did. I shouldn't have blamed the patient. Maybe I should've said that the person's choice to become a patient turns out to be fraught with unintended and, in the patient's case, unforeseeable, negative consequences. The consequences are not just borne by the patient, society at large continues to pay a heavy price.

Have you looked at the data on outcomes from lumbar spinal fusion surgery? They're abysmal. However, I've seen no abatement in the rate at which this procedure is performed.

According to a large study in the US in 2003 by McGlynn et al (New England Journal of Medicine, vol. 348) delivery of the standard of care for chronic conditions ranged from 10% (alcohol dependency) to less than 80% (senile cataract). The standard of care for low back pain was delivered <70% and for orthopedic conditions in general <60% of the time. Although this data is a decade old, I have no reason to think that much has changed in the last 10 years.

I'd highly recommend Nortin Hadler's book The Last Well Person regarding the specter of medicalization in our modern, Western cultures. It's a very sobering account of the current state of affairs.

[marcel]

John,
No worries, It is an interesting point of view that becoming a patient so to speak can sometimes be quite unhelpful in the "road" to recovery and not being the patient.

Maybe (in the context of neurobiology) we can lead patients towards a CHOICE of not being a patient. I guess this needs better phrasing ie better words.

I haven't looked at outcomes from lumbar spinal fusion surgery why are they so hopelessly bad? Perception and realization of why these people "need" this could play a (big?) role.
I'm quite busy making a reference list for a therapeutic education aproach a la explain pain, TNE and a few others.

Cheers

[BobV]

On medicalization:

As society is changing the problem of medicalization will change. As the problem of medicalization changes, we should look foor more fit definitions.

I like to view medicalization as it being a social problem forced into medical terms, viewing it from a Thomas Szasz point of view. However, neurfysiology tends to do the same thing by means of neuro reductionism. From that point of view, explanatory models like de body-self neuromatrix of pain, are in a way a form of medicalization. I often think on how Foucault would have contributed to a ICF-approach of PT. Is it all about accepting pain, rather than explaining pain? When we explain pain, or focus on standardized functional outcome measures, aren't we already in the field of medicalization?

http://www.pageout.net/user/www/m/i/...calization.pdf

Bob

[PatrickL]

Treating pain requires intervention in the form of education as a minimum. Therefore we are not self corrective.

This is only true if getting rid of pain required treating pain. Becoming a patient is optional, yes?

Exactly. Becoming a patient is a CHOICE. Unfortunately, within the current perverse culture of medicalization, it often turns out to be an unwise one.

Now you say self-correction my not be effective even though countless people in pain recover without consciously doing anything.

Cory, you can interpret my comment in 2 ways. The first, which is the way I think you interpreted it, is that if as a PT, I am dealing with a patient (someone who has already decided to become a patient), treating pain requires intervention in the form of education as a minimum. Or perhaps at a minimum it could be empathy and reflective listening. I don't think we can be certain that the intervention, whether it is education, empathetic presence, light touch or passive movement is simply a catalyst for self correction. I don't know how we can rule out the notion that the intervention, whatever form it takes, is not part of the process of correction. We can never go back in time after intervening, to see if the patient would have corrected if left to his/her own devices.

The second way to interpret my comment, is that treating pain at a broader population level in a preventive manner, requires education as a minimum. John referred up thread to a hypothetical longitudinal study investigating effects of education on persistent pain years down the track. If such a study revealed reduced prevalence of persistent pain problems, it would suggest that in the face of our current culture, we fail to self correct.

The counter argument is that if the culture wasn't so skewed towards medicalization of pain in the first place (and notwithstanding other cultural influences "I want it fixed now", affluenza), there wouldn't be a need to educate the population in a different direction. But our culture is our culture. If it is screwing up self corrective mechanisms for significant chunks of the population, then, unless each individual works it out for himself/herself that resolving persistent mechanical pain might be dependent on movement that reduces mechanical deformation, it's going to require intervention(s). Therefore, while we retain a capacity for self correction, those with persistent pain are proof that in our current culture they are not able to "correct" without some help.

If a PT argues that the "help" is really just a catalyst for self correction, the assumption is that in time, the patient would reach resolution in the absence of said catalyst. If one argued that the "help" assists resolution, the assumption is that the patient would not reach resolution if left to their own devices.

Neither of these assumptions can be tested without a time machine, so I can't see how this debate can be resolved.

I'd like to quickly say thanks to all those who have participated in this thread. I hope there are no hard feelings Diane, Barrett, nari and john. I think we share many more similarities as PTs than we have differences. And I am aware that the similarities we share are mostly, if not all because I have adopted your ideas. I am always going to be the type to critique ideas, especially the ones I agree with. So I hope you don't interpret my arguing here as though I've concluded that the ideas being debated are "wrong". I'm just crash testing them. It's how I learn.

[Ken Jakalski]

Hi Patrick!

But our culture is our culture. If it is screwing up self corrective mechanisms for significant chunks of the population, then, unless each individual works it out for himself/herself that resolving persistent mechanical pain might be dependent on movement that reduces mechanical deformation, it's going to require intervention(s)

What you've written made me think of what happened when my wife was delivering our first child thirty-five years ago. A mom in the room next to ours was moaning rather loudly during her contractions.

When the nurse came in to check on my wife, it was as if she knew we were unnerved by what we were hearing, and were probably wondering if this is what the next several hours would be like for us as well.

Her only response after we heard more moans from the next room:

"That's just a cultural thing."