Another reason therapists don't know

[Evanthis Raftopoulos]

I guess that means "No, I'm not going to describe what I do, demonstrate it or defend it."

Of course, I could be wrong, and Evan is certainly under no such obligation.

Well Barrett, that looks to me like your second tu quoque attempt. Last time I responded I didn’t get the impression that you cared of what I had to say. If you think I'm wrong though and you have an honest question to ask then I'm all ears.

[Barrett Dorko]

Now I'm supposed to ask you questions? I'm supposed to guess?

You've been asked if you wouldn't mind describing something about your actual practice. If you don't want to do that, fine.

[Evanthis Raftopoulos]

I was wondering out loud how you explain your rationale for treating pain with your patients. Since you've never provided so much as an anecdotal report, all we have to go on is dozens if not hundreds of comments where you theorize. Nothing wrong with that. I'm just wondering where this rubber meets the road for you.

We are moving away from ideomotion and SC.

John, I actually try not to claim that I treat ‘pain’, not at this point in time. A few issues/concerns off the top of my head 1.'pain' is yet to be successfully modeled, 2. It suggests that a definable cause-effect relationship exists between [insert treatment] and 'pain', which can also suggest that 'pain' is something concrete/uni-dimensional. 3. The current literature (per my interpretation) suggests that no intervention in the context of pain resolution is predictable. 4. post hoc story telling: 'pain' usually improves with or without treatment, whatever treatment the individual is having during this time usually takes the credit and reinforces the idea that it treats 'pain'

Most of what I do is offering support by encouraging movement/function when it's not there and the individual wants it back. Pain usually improves, but that can be more due to regression to the mean and other individual factors than anything that has to do with the PT encounter. I realize that I could be wrong, but I can't claim causation based on clinical observations alone. The current literature does not seem to support such a claim either for most msk manifested conditions. So some examples of what I can usually claim that I can offer is

- education of what's happening to them to the best of my knowledge.
- a prognosis
- set up together a 'plan of care' to help provide structure to their recovery (eg. set goals)
- exercise guidelines for the purpose of improving health/functionality (that take into consideration their problem)
- provide a safe environment to practice what is perceived as limited/challenge self as a way of monitoring progress
- some form of temporary relief (not always)


I realize that one could argue that the above can be considered as treating 'pain', but due to the reasons stated, I'm not very comfortable with claiming that. I'm interested in hearing what others think about this. Perhaps it's more appropriate to start a new thread.

[Evanthis Raftopoulos]

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.

Does this mean you're not going to share with us how you communicate what you do with your patients?

There you have it http://www.somasimple.com/forums/showthread.php?t=17926 , ask me whatever you want.

[PatrickL]

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.

I'd only add this:

If one argued that the "help" assists resolution, the assumption is that the patient would not reach resolution AS QUICKLY if left to their own devices.

i disagree. perhaps using the word "assist" made my comment ambiguous. I'll attempt to restate

1. 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.
2. If one argued that the "help" assists (meaning the intervention is an active part of the resolution, not just a catalyst e.g. education), the assumption is that the patient would not reach resolution if left to their own devices.

your "as quickly" qualifier is really just another way of "assuming that in time, the patient would reach resolution in the absence of said catalyst". i.e. the catalyst gets them to resolution faster. its all part of "1" above.


"2" assumes that an intervention is an active part of resolution, and assumes that the resolution would not occur without it. I'm not suggesting that I only agree with "2" and and/or that I disagree with "1". In this thread, I've been debating in favour of the notion that "2" exists.


But since we cant test either assumption from "1" or "2", we cant really rule either of them out. This means that it doesn't make sense to build a basic premise for treatment of pain on "1", since we need to account for "2".

[gerry the neck]

"John, I actually try not to claim that I treat ‘pain’, not at this point in time. A few issues/concerns off the top of my head 1.'pain' is yet to be successfully modeled, 2. It suggests that a definable cause-effect relationship exists between [insert treatment] and 'pain', which can also suggest that 'pain' is something concrete/uni-dimensional. 3. The current literature (per my interpretation) suggests that no intervention in the context of pain resolution is predictable. 4. post hoc story telling: 'pain' usually improves with or without treatment, whatever treatment the individual is having during this time usually takes the credit and reinforces the idea that it treats 'pain'"

Spot on. Begs the question.....Does the credit get claimed despite a lack of understanding of the internal processes ?

"Quote:
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."

Resolution is not the issue. Alleviation, even just temporary, is the issue, as I'm sure any chronic pain patient would testify. Resolution is reserved for conditions which can resolve, only.

[Diane]

I found a nice picture in google images of a diagram for movement, volitional and non-volitional, from BMJ. Seriously, the only "volitional" bit is prefrontal cortex, wouldn't you agree?

[BobV]

@Diane
Nice pic

But Volition is neither structur nor physiology. Volition is a process (or in ICF terminology: function). So I will have to disagree that the only volition is the neuroncrackling in the prefrontal cortex. However the prefrontal cortex is a necessary structure for human volition, however without all other structures allowing the observations to be compared and fit with the expectacy / prediction and vice versa there is nothing to decide to, nor to commit to.

http://en.wikipedia.org/wiki/Volition_(psychology)

Bob

[Josh]

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.

I agree Cory, which is kind of my point. We are complex creatures that rely on learning not instincts, which are obviously different than reflexes. Thats why I think its inaccurate to refer to movement that reduces mechanical deformation as instinctive movement or self-corrective ideomotion. Therefore if we learn to correct vs unlock culturally suppressed instinctual ideomotion, any technique or method that claims to catalyze the second should be questioned.

The first time my foot goes numb after crossing my legs for 30 min, I could react by moving my foot, wiggling my toes, lifting my arm, but not until I uncrossed my leg, did my numbness go away. I learned that resolved my numbness, next time i won't mess around with my foot I'll just uncross my legs. Anyone with kids experiencing this can relate. My kids have come to me in the morning in tears holding their arm to their chest with a "sleepy" pinky, after they straightened their elbow out it got better. Why didn't they do this instinctively? Why did I try to move my foot before uncrossing my legs? My instincts and ability to self-correct were wrong. I relied on learning.

As therapists, we are teachers that work with, not on, patients to help them learn correction. This isn't a dictatorship in anyway. I ask a patient what movements are comfortable which are painful. We play around with volitional exercises that relieve pain so they learn how to self-correct or self-manage their condition. To me, this seems more defensible than claiming to use instinctual, non-conscious, non-volitional, or culturally surpressed motion.

[Barrett Dorko]

Josh says:

We are complex creatures that rely on learning not instincts...

I'm amazed.

[Chunk]

Josh says:



I'm amazed.

Josh, if you can get a copy, you should read "Pain the gift nobody wants" by Dr. Paul Brand. It's a fantastic memoir if nothing else. He talks about attempts to protect damage to the limbs of leprosy patients (who have no sensation) by educating them on what they should do (behaviour modification and vigilance to environmental threats) to protect their limbs. Long story short, they may learn what to do but are rarely successful in their attempts to prevent further problems (i.e. soft tissue damage).
Dr. Brand writes eloquently about our natural intrinsic volition to move and change position etc. to maintain tissue homeostasis; this may come from a learnt or conscious desire to do so but most of the time, it is without consideration.
Similarly, individuals with congenital analgesia (insensitivity to pain)...don't roll over in bed, they get nasty bed sores.......
Try to stand still for a while, see how long it takes to move. It's not learnt behaviour, your body demands you do for the sake of tissue homeostasis.

[Evanthis Raftopoulos]

Hi Chunk
"Dr. Brand writes eloquently about our natural intrinsic volition to move and change position etc. to maintain tissue homeostasis; this may come from a learnt or conscious desire to do so but most of the time, it is without consideration."

"Try to stand still for a while, see how long it takes to move. It's not learnt behaviour, your body demands you do for the sake of tissue homeostasis."

It's a biological drive but not necessarily an instinct. Instinctual behavior might as well have something to do with this, but once again, the problem here is that we cannot dissect out instinctual behaviors in humans. If we don't acknowledge this, we'll continue arguing in circles about instincts. Moreover, it's even more difficult to claim that the movement that follows SC is instinctual, or that SC catalyzes instinctual movement and in a meaningful way. From observing Barrett's videos (see above) it seems to me that this movement is more related to expectation/context than anything else. If we place our hands on someone without providing a narrative, such movement will not occur(at least not to the extend that people move in the videos). I have done this experiment many times.



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[gerry the neck]

"As therapists, we are teachers that work with, not on, patients to help them learn correction. This isn't a dictatorship in anyway. I ask a patient what movements are comfortable which are painful. We play around with volitional exercises that relieve pain so they learn how to self-correct or self-manage their condition. To me, this seems more defensible than claiming to use instinctual, non-conscious, non-volitional, or culturally surpressed motion."

From a recipient's perspective, absolutely more defensible. And not just defensible, which seems to be the litmus test these days, it is pro-active and enlightened. Looks like good value for money spent, to me.

Regarding the 'numb leg', I think we shouldn't draw comparisons between a temporary inconvenient event and a possible real threat event. Our N/S reactions are bound to be different....Some N/S processes, referred pain for instance, can confound both learned and instinctive reactions. Almost like it's meant to be !

[Diane]

It's a biological drive but not necessarily an instinct. Instinctual behavior might as well have something to do with this, but once again, the problem here is that we cannot dissect out instinctual behaviors in humans. If we don't acknowledge this, we'll continue arguing in circles about instincts. Moreover, it's even more difficult to claim that the movement that follows SC is instinctual, or that SC catalyzes instinctual movement and in a meaningful way. From observing Barrett's videos (see above) it seems to me that this movement is more related to expectation/context than anything else. If we place our hands on someone without providing a narrative, such movement will not occur(at least not to the extend that people move in the videos). I have done this experiment many times.

I'm studying the brainstem these days.
If you recall, it contains medulla, pons..
Fish invented it 500 million years ago. It hasn't changed much since. The midbrain has changed a little, I gather, and the forebrain (a lot!), but the hindbrain, not by much, when it comes to any homeostatic or sensorimotor integration functions conducted there. Nuclei that run our autonomic functions, integrate collaterals from ascending info coming up. Create motor output to save our butt.
These are completely automatic in that they require no thought and function in a mature way at/from birth.
The behaviour of these is not "learned." I don't know if their behaviour would be "instinctive" either. They do run the show, however. They are resilient, and respond in exquisitely sensitive ways to the rest of the brain, and to info coming up through the spinal cord, such as nociception, so Evan, how would you classify these?

[Barrett Dorko]

Evanthis says:

If we place our hands on someone without providing a narrative, such movement will not occur(at least not to the extend that people move in the videos). I have done this experiment many times.

Well, calling it an "experiment" is questionable, though I've spent many years observing that a narrative is unnecessary.

I have an explanation though. As Diane asks: How would you classify this motion?

Not actually there?

Perhaps Michael in the video can help us, or Bas.